NYC06FA184

NTSB accident investigation · Boeing 737-300 · Pittsburgh, PA · July 27, 2006

Accident · Minor injuriesField investigationFinal report
Date
July 27, 2006, 09:45 local (13:45 UTC)
Place
Pittsburgh, PA
Injuries
3 minor, 75 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N529AUBoeing 737-300
Weather
Visual (VMC) · Day
Status
Completed · report June 30, 2008
Report
Approved by Office Director
Parties
FAA/FSDO, US Airways, Boeing
FAA report
20060727030729A
Case key
64205

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 airplane tug driver's inadvertent movement of the tug gear shift lever from forward to reverse, which resulted in the nose landing gear collapse. Contributing to the accident was the defective gear shift lever.

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.

Airframe/component/system failure/malfunctionTaxi - pushback/tow
Landing gear,main gear strut - fracturedCause
Equipment,other - inadvertentDriver of vehicleCause
Airport equipment,ground support - failure,partialFactor

Analysis

During pushback, the airplane was seen to "bounce" up and down both at the nose and the tail, before the nose gear collapsed. Examination of the airplane revealed a broken lower drag brace that was buckled in compression, and fractured due to overstress. The tug was examined and the gear shift lever was found to be defective. It would not lock in the neutral gate, and could be moved easily through the gate between the forward and reverse gears. In addition, the tug experienced "hesitation and hard jerks" when shifting from forward to reverse. Skid marks at the scene were the same width as the tug's wheelbase, and were consistent with sudden engagement of the transmission.

Factual narrative

History of flight

On July 27, 2006, about 0945 eastern daylight time (EDT), US Airways flight 231, a Boeing 737-300, N529AU, experienced a nose landing gear collapse while being pushed back from gate B-27, at the Pittsburgh International Airport (PIT), Pittsburgh, Pennsylvania. The 2 certificated airline transport pilots, 3 cabin attendants, and 73 passengers were not injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The scheduled passenger flight, destined for Palm Beach International Airport (PBI), West Palm Beach, Florida, was conducted under 14 Code of Federal Regulations (CFR) Part 121.

In a written statement, the first officer said that during her preflight inspection, a ground crewman directed her attention to the nose landing gear wheel because it was not oriented with the nose of the airplane, but "cocked to one side." The crewman said that he might have to "realign the aircraft during the pushback."

The crew completed their preflight tasks through the "Before Start Checklist." During a "normal" pushback with the airplane in motion, the crew initiated a start on the number two engine, and the nose gear collapsed.

A review of written statements from ground crew personnel revealed that when the airplane parked at the gate, the nose wheel was aligned with the nose of the airplane. The crew installed the bypass pin, and attempted to install the tow bar in preparation for the subsequent pushback, but the nose gear migrated to the airplane's right, with no steering forces applied. Once the wheel stopped turning, the tow bar was attached, oriented about 35 to 45 degrees off the airplane's centerline.

The pushback was "normal," and the tug and the airplane aligned without difficulty. In a telephone interview, one ground crewman described the pushback as "smooth" and steady with no rapid accelerations, decelerations, or turns. He said that as the airplane slowed for the eventual disconnection of the tow bar, he heard a "snap" or "crack" and the nose gear collapsed.

A Federal Aviation Administration (FAA) inspector was in the passenger area and watched the pushback as the plane cleared the Jetway. When the aircraft came into his view he did not see anything odd until he watched the nose of the accident airplane "rise up about one foot [and] then the nose dropped to the ground...The motion of the nose was similar to a horse throwing up its head rapidly."

A US Airways employee, making a delivery in the area of the departure gate, waited for the pushback, because the airplane blocked his path. He stated, "The tug appeared to jerk hard just as it passed the Jetway." He stated that the tug slowed, the airplane bounced, "the tail went upwards in two motions," and then the nose contacted the ground.

Wreckage and impact information

National Transportation Safety Board aeronautical engineers examined the airplane at the scene on July 28, 2006. The collapse of the nose landing gear resulted in substantial damage to the aft wheel well bulkhead. Examination of the gear revealed that the lower drag brace was fractured at its center, and the flanges at the break were twisted. One fracture surface was sectioned from the brace, and forwarded to the Safety Board Materials Laboratory in Washington, D.C., for examination.

The airplane was released to the operator for repair, however; parts removed from the landing gear and landing gear steering systems during repair were retained for examination at a later date.

Test and research

On August 4, 2006, the drag brace section was examined in the Safety Board Materials Laboratory. Examination of the drag brace revealed that it was deformed due to compression buckling, and the fracture surfaces were consistent with overstress fracture. There was no evidence of any preexisting cracks.

The lower drag brace was reexamined and hardness testing was conducted in the Safety Board Materials Laboratory on October 12, 2006. Rockwell hardness testing revealed that the lower drag brace fell within the hardness range for tensile strength specified in the Boeing engineering drawing.

On August 16, 2006, the hydraulic components, tested under the supervision of Safety Board engineers, included the left and right steering actuators, the depressurization steering valve, the retract actuator, and the lock actuator. All five components met their individual test requirements.

On September 21, 2006, the airplane tug was examined by an engineer and a mechanic of US Airways. Initial testing revealed that shifting gears was "difficult," and that "shifting into reverse would result in long hesitation then hard jerks before [the tug] would move smoothly." The shift lever could easily move thru the neutral gate as the shifter moved back forth between forward and reverse gears. The engineer stated that there was no spring tension in the neutral gate to prevent accidental shifting from forward to reverse. The test was suspended, and the tug was quarantined for further testing under the supervision of an FAA aviation safety inspector.

Examination of the tug was repeated under the supervision of the FAA inspector. The tug was also driven forward at low speed, and the shift lever was moved thru the gate into reverse gear. According to the engineer, the force "nearly threw the driver out of the tug...This is believed to be the same violent force that acted on [the accident airplane's] nose gear." Examination also revealed that the transmission required servicing with "several cans" of transmission fluid. Following the tests, a new shifter was installed on the tug before it was placed back into service.

Examination of photographs of parallel skid marks at the scene revealed that the distance between them was identical to the tug's wheelbase, and were consistent with sudden engagement of the transmission.

The FAA inspector reviewed the operator's report, and concurred with its findings.

The flight data recorder (FDR) and the cockpit voice recorder (CVR) were forwarded to the Safety Board Recorders Laboratory in Washington, D.C. for examination. The recorders were reviewed by Safety Board staff, but no significant or pertinent details were noted. Therefore, a recorder group was not formed, and no transcripts were published.

Meteorological information

The weather reported at Pittsburgh International Airport included few clouds at 6,000 feet, with winds from 220 degrees at 10 knots. The temperature was 25 degrees Celsius, and the dew point was 20 degrees Celsius.

Aircraft

Registration
N529AU
Reported as
Boeing 737-300
Category
Airplane
Serial number
24411
Engines
CFM International, turbo fanCFM International, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
US Airways Inc, doing business as US Airways
Registered owner
Wells Fargo Bank Northweat NA Trustee
Airworthiness certificate
Standard, Transport
Departed
PIT · Pittsburgh, PA
Destination
PBI · West Palm Beach, FL
Flight plan
IFR
Airport
PIT · Pittsburgh International

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
Age
58
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
March 1, 2006
Seat
Left
Flight hours
18,227 total · 1,933 in this make and model
Role
Co-pilot
Age
51
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
May 1, 2006
Seat
Right
Flight hours
12,505 total · 2,306 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 10 knots
Visibility
7 statute miles
Lowest ceiling
11,000 ft broken
Temperature
77 °F, dew point 68 °F
Altimeter
29.96 inHg
Observed at
KPIT

FAA reports on this event · 1

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