# NTSB MIA95LA135: Boeing 727-232, N489DA, West Palm Beach, FL, May 24, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 24, 1995, 12:48 local (16:48 UTC) - Place: West Palm Beach, FL - Coordinates: 26.649612, -80.250854 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.6496&lon=-80.2509&mi=10 - Phase of flight: [Pushback/towing](https://openairdocs.org/ntsb-phases/200) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 136 uninjured - Status: Completed, report August 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 37771 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA95LA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37771/pdf - Page: https://openairdocs.org/ntsb/MIA95LA135 ## Probable cause THE FAILURE OF THE GROUND PUSHBACK CREW TO FOLLOW DELTA AIRLINES PUSHBACK PROCEDURES AND PLACE A SIGNALMAN FORWARD OF THE AIRCRAFT IN VIEW OF THE CAPTAIN DURING PUSHBACK. THIS RESULTED IN THE CAPTAIN NOT BEING AWARE THAT THE TUG TOW BAR HAD DISCONNECTED AND THE NEED FOR HIM TO APPLY BRAKES TO STOP THE AIRCRAFT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, taxi - pushback/tow - procedures/directives - not followed, ground personnel (cause) - landing gear,towbar/attachment - overload (contributing factor) - landing gear,towbar/attachment - disconnected (contributing factor) - object - vehicle ## Analysis THE AIRCRAFT WAS PUSHED BACK FROM THE GATE WITH TWO ENGINES OPERATING DUE TO AN INOPERATIVE APU. THE TUG DRIVER WAS ASSISTED BY TWO WING WALKERS. THERE WAS NO SIGNALMAN IN FRONT OF THE AIRCRAFT AS REQUIRED BY DELTA AIRLINES PUSHBACK PROCEDURES. AFTER PUSHING THE AIRCRAFT STRAIGHT BACK AND TURNING THE TAIL TO THE LEFT THE TUG WAS POSITIONED TO THE RIGHT FRONT OF THE AIRCRAFT. AS THE TUG MOVED FORWARD TO STRAIGHTEN THE NOSE GEAR THE SAFETY PIN ON THE TUG END OF THE TOW BAR SHEERED. THE AIRCRAFT BECAME DISCONNECTED FROM THE TUG AND ROLLED FORWARD STRIKING THE TUG WITH THE RIGHT FRONT AREA OF THE AIRCRAFT. AS THE AIRCRAFT ROLLED FORWARD THE TUG DRIVER'S HEADSET BECAME DISCONNECT FROM THE AIRCRAFT AND COMMUNICATION WITH THE COCKPIT CREW WAS LOST. ## Factual narrative On May 24, 1995, about 1248 eastern daylight time, a Boeing 727-232, N489DA, registered to Delta Air Lines, Inc., and operating as Delta flight 1522, scheduled domestic passenger service from West Palm Beach, Florida, to Atlanta, Georgia, sustained damage when it collided with a tug during pushback at West Palm Beach. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft sustained substantial damage. The airline transport-rated pilot, first officer, flight engineer, 3 flight attendants, and 130 passengers were not injured. The flight was originating at the time of the accident. The tug driver who was pushing N489DA from the gate stated that two of the aircraft's engines had been started before pushback due to the aircraft's power unit being inoperative. During the pushback there were two wing walkers. There was not a signal man in front of the aircraft in view of the captain, as required by Delta Air Lines pushback procedures, due to manpower shortages. He pushed the aircraft straight back and then turned the aircraft's tail to the left. The aircraft and tug made a "U" shape at this time with the tug on the aircraft's right front. As he moved the tug to straighten the aircraft's nose gear, the safety pin on the tug end of the tow bar sheered. He did not believe he turned the nose gear beyond the normal limits; however, it was a "sharp" turn. The aircraft became disconnected from the tug and rolled forward at which time the right front side of the aircraft struck the tug. As the aircraft rolled forward the tug driver's headset cord became disconnected from the aircraft and he lost communication with the cockpit crew. The left wingman arrived at the front of the aircraft at this time and signaled the captain to brake the aircraft and stop it. ## Aircraft - Registration: [N489DA](https://openairdocs.org/deregistered/N489DA-2000-08-16), registration cancelled 2000-08-16, S/N 21019 (OpenAirDocs) - Reported make and model: BOEING 727-232 - Registry model: [Boeing 727-232](https://openairdocs.org/model/boeing-727-232) (registry code 1384082) (OpenAirDocs) - Category: Airplane - Serial number: 21019 - Airframe hours: 60114 - Engines: P&W JT8D-15A 15500 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Registered owner: Delta Air Lines Inc - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, March 6, 1995, 600 hours before - Departed: PBI - Destination: ATL, ATLANTA, GA - Flight plan: IFR - Airport: PBI, Palm Beach International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 18,500 total, 9,000 in this make and model, 7,000 as pilot in command, 187 in the last 90 days, 70 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 13 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 72 °F - Altimeter: 30.00 inHg - Observed at: PBI, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19950524014959A](https://openairdocs.org/incident/19950524014959A), May 24, 1995: Boeing 727232, West Palm Beach, FL, Substantial damage. Collided with a tug during pushback at gate. Shear pin on towbar failed. 727 rolled forward fuselage hit tug. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.