MIA95LA086

NTSB accident investigation · Lockheed L-1011-385 · San Juan, PR · March 12, 1995

Accident · No injuriesLimited investigationFinal report
Date
March 12, 1995, 13:05 local (17:05 UTC)
Place
San Juan, PR
Injuries
339 uninjured
Phase of flight
Pushback/towing
Aircraft
N724DALockheed L-1011-385N376MQShort Brothers SD3-60
Weather
Visual (VMC) · Day
Status
Completed · report June 19, 1995
Report
Approved by Office Director
Case key
37739

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The tug operator of another airplane commencing pushback procedures without clearance to do so from the dispatching agent, resulting in an on-ground collision between both airplanes.

The failure of the tug operator to follow correct pushback procedures by commencing pushback without clearance, resulting in an on-ground collision with another airplane.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Collision between aircraft (other than midair)Taxi - pushback/tow
Procedures/directives - not followedGround personnelCause
Collision between aircraft (other than midair)Taxi - from landing
Procedures/directives - not followedGround personnelCause

Analysis

The American SD3-60 was cleared to the ramp behind a delta L-1011 that had commenced pushback procedures from a departure gate. The lead wing walker of the delta L-1011 observed the American SD3-60, and signalled the tug operator to stop the pushback which was complied with. The SD3-60 taxied past the l- 1011 and stopped on the ramp. The delta tug operator commenced pushback procedures without clearance from the dispatching agent. The right wing tip of the L-1011 collided with the rudder of the SD3-60. Delta airlines SOP states, the tug operator is responsible for following the signals of the dispatching agent.

The tug operator was cleared by the dispatching agent to commence pushback procedures at a departure gate on a Delta L- 1011. The lead wing walker observed an American SD3-60 taxiing to the ramp and signaled the tug operator to terminate the pushback, which was complied with. The tug operator observed the SD3-60 taxi past the L-1011, and commenced pushback procedures without clearance from the dispatching agent. The right wing tip of the L-1011 collided with the rudder of the SD3-60. Delta Airlines SOP states, the tug operator is responsible for following the signals of the dispatching agent.

Factual narrative

Same as narrative MIA95LA086A.

On March 12, 1995, about 1305 Atlantic standard time, a Lockheed L-1011, N724DA, flight number 189, experienced an on-ground collision during pushback at the Luis Munoz Marin International Airport, San Juan, Puerto Rico, with a Short SD3-60, N376MQ. The L-1011 is registered to Delta Airlines Inc., operating as a 14 CFR Part 121 scheduled domestic passenger flight. The Short SD3-60, is registered to Security Pacific esquire, operating as a 14 CFR Part 121 scheduled domestic passenger flight, by Executive Airlines Inc., doing business as American Eagle flight 5539. Visual meteorological conditions prevailed and an IFR flight plan was filed for both airplanes. The Delta Airlines airplane sustained minor damage and the American Eagle airplane sustained substantial damage. The Delta Airlines airline transport pilot-in-command, airline transport pilot first officer, flight engineer, 8 flight attendants, and 302 passengers were not injured. The American Eagle airline transport pilot-in-command, commercial pilot first officer, 1 flight attendant and 23 passengers were not injured. The Delta Airlines flight was originating at San Juan, Puerto Rico, and the American Eagle flight originated from St. Thomas, U.S. Virgin Islands, about 31 minutes before the accident.

The lead left wingman, for Delta Airlines flight 189 stated, they had just commenced pushback from gate 33 when he observed an American Eagle flight taxiing behind flight 189. He signaled the tug operator to stop the pushback. The American Eagle flight taxied past flight 189, stopped, started taxiing again, and stopped abruptly. The tug operator commenced pushback procedures without receiving instructions from the dispatching agent. The wingman signaled the tug operator to stop, however; the right wing tip of Delta flight 189 collided with the rudder of American Eagle flight 5539 before the pushback was stopped.

Review of ATC transcripts from the time period of 1255:00 to 1308:00 revealed American eagle flight 539 requested and received permission to taxi from runway 10 to the ramp at 1300:12. At 1300:40, Delta Airlines flight 189 requested pushback clearance from ground control, and was approved at 1300:43. American Eagle flight 539 advised ground control "that delta aircraft just hit us on our tail pushing back." Delta flight 189 requested and received permission from ground control to return to the departure gate at 1303:37.

The tug operator was interviewed by the FAA on March 12, 1995. The tug operator stated upon receiving initial clearance he began pushback operations, and stopped the pushback when he observed an American Eagle SD3-60 taxiing behind the aircraft from east to west. When he observed the SD3-60 on the west side of the L-1011, he resumed pushback operations, without receiving clearance from the dispatching agent.

Delta Airlines SOP states, the dispatching ramp agent is responsible for directing the movement of aircraft. It also states the dispatching ramp agent is responsible for observing obstruction clearance and executing the appropriate ramp signals to the tug operator. It further states the tug operator is responsible for following the signals of the dispatching ramp agent.

Aircraft · 2

Registration
N724DA
Reported as
Lockheed L-1011-385
Category
Airplane
Serial number
L1011385115
Airframe hours
58,199
Engine
Rolls-Royce RB-211-22B, 42,000 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Registered owner
Delta Airlines Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 17, 1995 · 217 hours before
Destination
ATL · Atlanta, GA
Flight plan
IFR
Airport
SJU · Luis Munoz Marin Intl.

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N376MQ
Reported as
Short Brothers SD3-60
Category
Airplane
Serial number
SH3685
Airframe hours
16,273
Engine
P&W PT6A65AR, turbo prop
Damage
Substantial damage
Flight
Part 121
Operator
Executive Airlines Inc., doing business as American Eagle
Registered owner
Executive Airlines Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 7, 1995 · 17 hours before
Departed
STT · St. Thomas
Flight plan
IFR
Airport
SJU · Luis Munoz Marin Intl.

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N724DA
Age
54
Certificates
Flight engineer, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
10,000 total · 547 in this make and model · 10 in the last 24 hours
Role
Pilot, aircraft N376MQ
Age
26
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
3,560 total · 1,190 in this make and model · 1,570 as pilot in command · 110 in the last 90 days · 25 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 14 knots
Visibility
13 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 64 °F
Altimeter
30.00 inHg
Observed at
SJU

FAA reports on this event · 2

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N724DA · 2

Matched to the same aircraft by N-number and date.