# NTSB NYC02LA056: McDonnell Douglas DC-9-32, N837AT, Dulles, VA, January 20, 2002 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 20, 2002, 07:15 local (12:15 UTC) - Place: Dulles, VA - Coordinates: 38.95, -77.446662 - Nearby events: https://openairdocs.org/map.md?lat=38.9500&lon=-77.4467&mi=10 - Phase of flight: [Pushback/towing](https://openairdocs.org/ntsb-phases/200) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 66 uninjured - Status: Completed, report April 17, 2003 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Airtrans - NTSB case key (mKey): 54107 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC02LA056 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54107/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54107 - Page: https://openairdocs.org/ntsb/NYC02LA056 ## Probable cause The lack of direction from the operator on how to perform pushbacks on an icy ramp, which led to the tug driver positioning the tug at an angle to the nose of the airplane that allowed the airplane to move forward and strike the tug. Factors were the inadequate visual lookout by the walker wearing the headset, and the icy ramp. ## 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 - inadequate, company/operator management (cause) - terrain condition - icy (contributing factor) - visual lookout - inadequate, other person (contributing factor) ## Analysis The DC-9-32 was parked at the gate, with an inoperative APU, and the ramp was covered with snow and ice. The captain reported that a single engine cross bleed start would require an N1 of about 80% on the operative engine. He therefore elected to start both engines at the gate, and then proceed with the pushback. The operators manual stated that if a headset was used, it would be worn by the tug driver. The tug driver did not wear the headset because the headset chord had been broken and repaired multiple times, and was too short to reach the tug driver. A walker near the nose of the airplane was wearing the headset. During pushback, as the tug driver tried to push the nose of the airplane to the west, the airplane encountered icy conditions, moved forward, and struck the tug. At the time of loss of traction, the tug was nearly 90 degrees to the right side of the nose of the airplane. The forward movement of the airplane was observed by the tug driver, who stopped the tug, but with no headset, he could not notify the cockpit crew. The walker near the nose of the airplane, wearing the headset, reported that he was looking away, and did not observe the airplane moving forward in time to make a call to the cockpit. The pushback was accomplished by a contract crew that had been trained in accordance with the airlines GMM, which did not contain specific direction for pushbacks on icy surfaces. ## Factual narrative On January 20, 2002, at 0715 eastern standard time, a McDonnell Douglas DC-9-32, N837AT, operated by Air Tran Airways as flight 67, was substantially damaged during pushback at Washington Dulles International Airport, Dulles, Virginia. There were no injuries to the 2 certificated airline transport pilots, 3 flight attendants, or 61 passengers. Visual meteorological conditions prevailed. An instrument flight rules (IFR) flight plan had been filed, for the flight that was conducted under 14 CFR Part 121. The flight was destined for Atlanta, Georgia. According to the captain, the ramp was covered with snow and ice, and their gate position required a pushback with a nose swing of about 120 degrees. The airplane had an inoperative APU, and he elected to start both engines at the gate prior to pushback because a single engine crossbleed start would require an N1 of 80 percent on the operative engine. After both engines were started, the pushback was initiated. As the tug neared a 90 degree position to the right side of the nose of the airplane, it started to move forward, and then stopped when it struck the tug, after which the captain set the brakes. The captain added that he had not applied the brakes until after the airplane came to rest. According to the diagrams on the Air Tran Airways safety report filled out by the captain, the position of the tug was near 90 degrees to the right of the nose of the airplane when the airplane started to move forward. According to an interview conducted with the tug driver by the Metropolitan Washington Airports Authority, Airport Operations Division, the tug driver reported that he had conducted two earlier pushback with no problems. The tug driver added that with both engines running on the airplane, the airplane felt heavier during the push. During the pushback, there were two wing walkers, the tug driver, and an additional walker near the nose of the airplane, who was using a headset to remain in communications with the flight crew. The people who conducted the pushback were contract employees who had been trained in accordance with Air Tran Airways general maintenance manual (GMM). There was no specific requirement to use a headset. However, the Air Tran Airways GMM did state that headset communication was the primary method of communications during pushback and tow. It further stated, "If an interphone/headset is to be used, the tractor operator will man the headset...." The investigation revealed that the tug driver did not wear the headset because the chord had broken, and had been repaired several times, which shortened its overall length. The tug driver reported that he had already pushed back two airplanes that morning with no problems, and that the initial part of the push was without incident. As the airplane entered an area where the ramp was icy, he turned the nose of the airplane to the west. The nosewheels on the airplane started slipping, and he was unable to communicate this to the cockpit crew. He stopped the tug and the airplane slid into the tug. The walker on the interphone to the cockpit reported that he was not looking at the airplane when it began to slip. When he became aware that the airplane was slipping, there was insufficient time to tell the flight crew to set the brakes. He did not make any transmission to the pilots prior to impact. The ramp was reported as icy, and some people reported difficulty in walking. The tug used for pushback was a Hough T-225, rated to push an airplane up to 225,000 pounds. The tires on the tug were not equipped with chains. The ramp had not been sanded. Within the preceding 12 hours, the airport had reported periods of freezing rain, followed by light snow. A toxicological report on the tug driver was negative for drugs or alcohol. Neither Air Tran Airways, nor the contract operator had any specific training directed to the problems that could be encountered with pushing airplanes on icy ramps, or winter operations in general. Damage to the airplane consisted of a hole in the right side of the fuselage, located about 3 feet below the bottom of the forward, right side cabin door, and about 4 feet behind the trailing edge of the door. Internally, there was damage to the longerons. ## Aircraft - Registration: [N837AT](https://openairdocs.org/deregistered/N837AT-2004-01-12), registration cancelled 2004-01-12, S/N 45774, built 1968 (OpenAirDocs) - Reported make and model: McDonnell Douglas DC-9-32 - Registry model: [Mcdonnell Douglas DC-9-32](https://openairdocs.org/model/mcdonnell-douglas-dc-9-32) (registry code 302206C) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT8D-9 series](https://openairdocs.org/engine/pratt-whitney-jt8d-9-series) (registry code 52048, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 45774 - Airframe hours: 67712 - Engines: Pratt & Whitney JT8D-9 14500 lbs thrust turbo fan; Pratt & Whitney JT8D-9 14500 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Registered owner: Air Trans Airways - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, March 1, 2000 - Departed: Dulles, VA - Destination: ATL, Atlanta, GA - Flight plan: IFR - Airport: IAD, Washington Dulles ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: none; flight engineer, airline transport, flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; last flight review September 11, 2001; seat: left; flight hours: 12,500 total, 7,000 in this make and model, 6,000 as pilot in command, 240 in the last 90 days, 80 in the last 30 days, 5 in the last 24 hours - Co-pilot; age 58; injuries: none; commercial, airline transport, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review November 1, 2001; seat: right; flight hours: 14,500 total, 4,521 in this make and model, 2,200 as pilot in command ## Weather - Conditions: Visual (VMC), Dusk - Wind: 360° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 30 °F, dew point 23 °F - Altimeter: 30.11 inHg - Observed at: IAD ## 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 20020120002439A](https://openairdocs.org/incident/20020120002439A), Jan 20, 2002: Doug DC932, Washington, DC, No damage. (-23) During pushback from gate B-24 on icy ramp with both engines running tug driver began turning the aircraft as he approached the vehicle lanes. As the… ## Docket (8 files) The files NTSB released with the investigation on January 28, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54107. 1.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380534&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Air Tran Flight Operations Safety Report (item 2, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380536&FileExtension=.PDF&FileName=Air%20Tran%20Flight%20Operations%20Safety%20Report-Redacted.PDF - Statement of Person Wearing Headset (item 3, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380537&FileExtension=.PDF&FileName=Statement%20of%20Person%20Wearing%20Headset-Redacted.PDF - Statement of tug driver (item 4, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174422&FileExtension=.PDF&FileName=Statement%20of%20tug%20driver-Master.PDF - Report from Swissport (item 5, .PDF, 395 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174423&FileExtension=.PDF&FileName=Report%20from%20Swissport-Master.PDF - Training Record for Tug Driver (item 6, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380539&FileExtension=.PDF&FileName=Training%20Record%20for%20Tug%20Driver-Redacted.PDF - Airport Police Report (item 7, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380541&FileExtension=.PDF&FileName=Airport%20Police%20Report-Redacted.PDF - Air Tran GMM (excerpted) (item 8, .PDF, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174692&FileExtension=.PDF&FileName=Air%20Tran%20GMM%20(excerpted)-Master.PDF 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.