MIA95LA218

NTSB accident investigation · Boeing 737-4Q8 · Miami, FL · September 6, 1995

Accident · No injuriesLimited investigationFinal report
Date
September 6, 1995, 12:20 local (16:20 UTC)
Place
Miami, FL
Injuries
78 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N405KWBoeing 737-4Q8
Weather
Visual (VMC) · Day
Status
Completed · report April 1, 1996
Report
Approved by Office Director
FAA report
19950906032649A
Case key
37823

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

Improper planning/decision by the company driver of the vehicle (paymover) and uncommanded movement of the paymover for undetermined reasons.

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.

On ground/water collision with objectTaxi - pushback/tow
Object - ground power unitCause
Miscellaneous equipment - uncontrolledDriver of vehicleCause
Planning/decision - improperDriver of vehicleCause

Analysis

A ground support employee was attempting without assistance to connect the towbar to the paymover to push back the airplane from the gate. The paymover reportedly moved uncommanded rearward and collided with other ground equipment. The engine of the paymover was shut down and a ground support supervisor boarded the paymover to again attempt to pushback the airplane. The supervisor stated that while standing on the paymover with the parking brake released after starting the engine, the paymover moved uncommanded forward. Attempts to stop it were unsuccessful. The paymover collided with the towbar then with a ground power unit which was pushed into the fuselage. The normal brake system which was not repaired after the accident was operationally tested after the accident; no defects were noted. Operational test of neutral safety switch could not duplicate the malfunction. Similar discrepancies regarding uncommanded movement of the paymover were reported.

Factual narrative

On September 6, 1995, about 1220 eastern daylight time, a Boeing 737-4Q8, N405KW, registered to International Lease Finance Corporation, operated by Carnival Air Lines, Inc., was substantially damaged while attempting to push back from a gate at the Miami International Airport, Miami, Florida. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed for the 14 CFR Part 121 scheduled, international, passenger flight. The captain, first officer, cabin crew of 4, and 72 passengers were not injured. The flight was originating at the time of the accident.

An employee of the company that provides ground support stated that the towbar was first connected to the airplane. He then positioned the paymover and attempted without assistance to connect the towbar to the paymover. The paymover then moved uncommanded rearward and collided with a container loader. The engine of the paymover was then shut down and the captain and a ground support supervisor who were on the flight deck inspected the airplane for damage; none was noted. The captain returned to the flight deck and the supervisor boarded the paymover. The supervisor stated that while standing on the paymover he disengaged the parking brake, applied the normal brakes, and started the engine of the paymover. Immediately after the engine was started the paymover moved uncommanded forward and attempts to stop the paymover using the normal brakes were unsuccessful. The paymover then collided with the towbar and a ground power unit which was pushed into the fuselage. The supervisor further stated that he operates similar paymovers daily.

Following the accident, damage to the tug was repaired; however, the normal brake system of the tug was not worked on. The neutral safety switch which is designed to prevent starting of the engine with the transmission in drive or reverse was operationally checked for failure or malfunction, with no defects noted. Additionally, postaccident operational testing of the normal brakes at near full acceleration revealed no evidence of failure or malfunction.

According to the cargo manager, the paymover involved in the accident had been in the shop for maintenance on August 28, 1995, and during testing, the engine started once while the transmission selector was in the "drive" position. Attempts to duplicate were unsuccessful. The paymover was returned to service.

According to the training manager he experienced a similar occurrence involving uncommanded movement of the same paymover but the normal brakes stopped the paymover. He also stated that discrepancies with ground support equipment are verbally reported to maintenance.

Review of maintenance work orders for the accident paymover from March 1994, to the date of the accident revealed no similar discrepancies.

Aircraft

Registration
N405KW
Reported as
Boeing 737-4Q8
Category
Airplane
Serial number
24704
Airframe hours
10,624
Engine
CFM CFM-56-3C-1, 22,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Carnival Air Lines, Inc.
Registered owner
International Lease Finance Co
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · August 19, 1995 · 154 hours before
Departed
MIA
Destination
MTPP · Port-Au-Prince, OF
Flight plan
IFR
Airport
MIA · Miami International

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
39
Certificates
Flight engineer, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
11,276 total · 5,455 in this make and model · 8,197 as pilot in command · 176 in the last 90 days · 58 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 7 knots
Visibility
7 statute miles
Lowest ceiling
25,000 ft broken
Temperature
88 °F, dew point 73 °F
Altimeter
29.00 inHg
Observed at
MIA, 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.