SEA08LA182

NTSB accident investigation · Boeing 777-300 · San Francisco, CA · August 16, 2008

Accident · Serious injuriesLimited investigationFinal report
Date
August 16, 2008, 01:50 local (08:50 UTC)
Place
San Francisco, CA
Injuries
1 serious, 311 uninjured; on the ground: 1 serious
Damage
No damage
Phase of flight
Standing
Aircraft
B-16710Boeing 777-300
Defining event
Standing-engine(s) operating: Ground handling event
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 12, 2009
Report
Approved by Office Director
Parties
Aviation Safety Council, FAA SFO International Field Office
Case key
68725

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

On this page

Probable cause

The ground crewman's failure to follow the tow bar disconnect standard operating procedures.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Towing and taxiingAircraft › Aircraft handling/service · Incorrect use/operationAll aircraft: 2 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Ground crewAll aircraft: 1,386 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Ground crewAll aircraft: 191 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Ground handling eventStanding-engine(s) operatingAll aircraft: 108 casesDefining event

Analysis

The transport airplane had been pushed back from the gate and the engines were started. Ground personnel attempted to disconnect the tow bar but had difficulty. They instructed the flight crew to release the parking brake in order to reposition the nose gear. The mechanic attempted to disconnect the tow bar and when it finally disconnected, the airplane moved forward and he was pinned under the left nose gear. The ground crew management and airline personnel indicated that the ground crew personnel were not acting in accordance with established standard operating procedures which requires that the parking brake be set prior to removal of the tow bar.

Factual narrative

On August 16, 2008, at 0150 Pacific daylight time, Eva Air 17, Taiwanese registry B16710, a Boeing 777-300, was being pushed back from the gate when a mechanic was pinned under the left nose gear at San Francisco International Airport, San Francisco, California. The flight crew and passengers were not injured; the mechanic sustained serious injuries. There was no damage to the airplane. Eva Air was operating the airplane under the provisions of 14 Code of Federal Regulations Part 129. The scheduled international passenger flight was destined for Taoyuan International Airport, Taipei, Taiwan. Visual meteorological conditions prevailed and an instrument flight plan was filed. According to airport operations personnel, an Eva Air mechanic and a Swissport ground agent were pushing the flight back from the gate. The ground agent reported that the mechanic had difficulty unhooking the tow bar from the airplane and began jumping on it and standing in front of the nose gear. When the tow bar fell, the airplane lurched forward and pinned the mechanic under the left nose gear. In a written statement submitted by flight crew personnel, they stated that the airplane was pushed back and the engines were started. The flight crew instructed the ground handling crew to disconnect the tow bar and advise when they were clear to taxi. The ground crew had difficulty removing the tow bar and advised that they intended to straighten the airplane by towing it forward in order to release the tow bar. The ground crew instructed the flight crew to release the parking break and the airplane rolled over the mechanic. The Eva Air mechanic reported that normally, ground agents handle the pushback. The ground agent had difficulty unhooking the tow bar from the airplane. Due to this difficulty, the mechanic came to assist and then suggested that the airplane be towed forward to straighten the airplane and tug. The ground agent then requested that the pilot release the parking brake. The airplane was towed forward, and the ground agent attempted to disconnect the tow bar; however, he still had difficulty. The ground agent went to the tug and the mechanic came to check the condition of the tow bar which he reported was half unhooked. The mechanic tried to disconnect the tow bar by stepping on it, it eventually disconnected from the airplane, and the airplane began to roll forward. The mechanic shouted to the ground agent to "set the parking brake" and then the mechanic fell on the ground. The airplane continued to roll forward and pinned the mechanic's leg. The mechanic reported that the normal procedure of disconnecting a tow bar requires that the parking brake be set, chocks are in, tug disconnected from the tow bar, and then the tow bar disconnected from the airplane. The Swissport Station Manager and Eva Air personnel indicated that the ground handling of the airplane was not in accordance with established standard operating procedures. Normal procedure requires that theparking brake be set, prior to removal of the tow bar.

Aircraft

Registration
B-16710
Reported as
Boeing 777-300
Category
Airplane
Serial number
32641
Airframe hours
1,894.54
Engine
General Electric GE90-115B, 115,540 lbs thrust, turbo fan
Damage
No damage
Flight
Part 129
Operator
Eva Air
Registered owner
Eva Air
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · July 31, 2008 · 234 hours before
Departed
SFO · San Francisco, CA
Destination
TPE · Taipei
Flight plan
IFR
Airport
SFO · San Francisco International

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
None
Certificate
Foreign
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 23, 2008
Seat
Left
Flight hours
12,123 total · 1,494 in this make and model · 5,045 as pilot in command · 227 in the last 90 days · 46 in the last 30 days
Role
Co-pilot
Age
42
Injuries
None
Certificate
Foreign
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 24, 2008
Seat
Right
Flight hours
5,452 total · 1,150 in this make and model · 240 in the last 90 days · 75 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
300° at 9 knots
Visibility
10 statute miles
Lowest ceiling
13,000 ft broken
Temperature
57 °F, dew point 55 °F
Altimeter
29.87 inHg
Observed at
SFO

Docket · 3

The files NTSB released with the investigation on March 23, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 999 KB in all.