WPR10FA199

NTSB accident investigation · Boeing 737-3H4 · Los Angeles, CA · April 10, 2010

Accident · No injuriesField investigationFinal report
Date
April 9, 2010, 19:30 local (Apr 10, 2010, 02:30 UTC)
Place
Los Angeles, CA
Injuries
109 uninjured
Damage
Substantial damage
Phase of flight
Pushback/towing
Aircraft
N624SWBoeing 737-3H4
Defining event
Pushback/tow-engine oper: Ground handling event
Weather
Visual (VMC) · Dusk
Status
Completed · report May 23, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Southwest Airlines
FAA report
20100409034329A
Case key
75710

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 tug operator’s failure to comply with company procedures when parking an unoccupied baggage tug, and the failure of the tug’s seat switch to disengage the electric motor when weight was removed from the driver’s seat.

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.

ActionPersonnel issues › Action/decision · Ground crewBoeing 737-3H4: 1 caseAll aircraft: 111 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Ground crewBoeing 737-3H4: 1 caseAll aircraft: 191 casesProbable cause
Object/animal/substance: ground vehicleEnvironmental issues › Physical environment · Contributed to outcomeBoeing 737-3H4: 1 caseAll aircraft: 132 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.

Analysis

While the airplane was being pushed back for its flight, it was struck by a runaway baggage tug. The tug operator reported that he stopped on the ramp to pick up two bags. He exited the tug without setting its parking brake, turning off its engine, or placing the gear selector in neutral or park, which was not in accordance with the tug company’s ground equipment general driving rules. The tug operator then placed the first bag on the passenger seat, which company procedures caution against doing. While the tug operator was handling the second bag, the unoccupied tug began to move because the first bag had fallen off the passenger seat onto the accelerator pedal. The tug moved forward, struck a hydrant fueling cart on the ramp, and then veered toward the left side of the airplane. The tug impacted both of the airplane’s engines and its fuselage. If the tug operator had followed company driving rules, the accident could have been prevented. In addition, postaccident examination of the tug revealed that the electrical motor disengaging seat switch, which is designed to disengage the tug's electrical motor when weight is removed from the driver's seat, was inoperative; therefore, it did not prevent the tug from moving forward as designed.

Factual narrative

HISTORY OF FLIGHT On April 9, 2010, about 1930 Pacific daylight time, a Boeing 737-3H4, N624SW, sustained substantial damage when it was struck by a runaway baggage tug at the Los Angeles International Airport, Los Angeles, California. At the time, the airplane had one engine operating and was being pushed back for its flight by a pushback tug. None of the 2 airline transport pilots, the 3 flight attendants, or the 104 passengers were injured. There were no reported ground injuries. The airplane was registered to and operated by Southwest Airlines as flight number 579, under the provisions of Title 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The scheduled domestic passenger flight had a planned destination of the Tucson International Airport, Tucson, Arizona. In a written statement, an airline ground service employee reported he drove a baggage tug close to gate 3, terminal 1, whereupon he exited the tug with the gear selector in forward and without setting the parking brake or turning off its electric motor. The employee reported he then walked around the tug to pick up two bags that were placed on the ramp. He picked up one of the bags and placed it on the passenger's seat of the unoccupied tug. As the employee was handling the second bag, he observed that the tug had started to move and was traveling in the direction of a hydrant fueling cart that was parked between gates 3 and 5. The ground service employee ran after the tug to get aboard it and attempt to stop its movement. He attempted to apply the brakes but had to exit the tug before it impacted the airplane. He stated that prior to exiting the tug, he noticed that the first bag he had placed on the tug was on the floor and likely resting on the accelerator pedal. The company issued a Safety Advisory (SA 10-06) on the accident that stated that the bag fell off the seat and onto the tug’s accelerator. Ground service employees located on the ramp near gate 3 stated that, initially, the tug rolled forward about 30 feet until it struck a hydrant fueling cart. The runaway tug veered off the side of the cart and continued rolling about 130 feet until it impacted the airplane’s number 1 engine. Subsequently, the tug impacted the left, lower side of the airplane's fuselage and belly, and proceeded beneath the airplane and came to a stop upon impacting the number 2 engine. DAMAGE TO AIRCRAFT Examination of the airplane by maintenance personnel revealed that the fuselage exhibited various skin punctures, dents and an internal frame shear tie was bent. The number 1 engine sustained damage to its cowl. The number 2 engine sustained damage to the engine, engine components, engine cowl and the engine pylon (including wing fairings, pylon structure, and mid-spar fitting to under wing fitting fuse pins). PERSONNEL INFORMATION The 47 year-old tug operator was on his first day back to work following an extendedleave of about 2 months. He has been employed with the company for about 7 ½ years. He received his initial Powered Industrial Truck Training (PITT) on December 13, 2006, and his three year refresher PITT training was completed on October 16, 2009. TESTS AND RESEARCH Examination of the tug by a National Transportation Safety Board (NTSB) investigator revealed that the seat switch was inoperative. According to the tug operator’s guide, when weight is removed from the driver's seat, the seat switch is designed to open the electric circuit thereby disengaging the tug's electrical motor. The weight activated switch is located beneath the driver's seat. Post-accident testing revealed that the tug would not move while pushing down on the accelerator pedal if the parking brake was set or the brakes applied, or with the directional control level in the neutral position. The company ground equipment general driving rules require unoccupied vehicles on the ramp to be placed in park or neutral, with the parking brake set and the engine turned off. The company ground equipment general driving rules has a caution which states never to transport any items (e.g., baggage, freight) on top of or in the passenger seating area of a vehicle.

Aircraft

Registration
N624SW
Reported as
Boeing 737-3H4
Category
Airplane
Serial number
27934
Airframe hours
46,873
Engines
General Electric CFM 56-3, 20,000 lbs thrust, turbo fanGeneral Electric CFM 56-3, 20,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Southwest Airlines Co
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 7, 2010
Departed
LAX · Los Angeles, CA
Destination
TUS · Tucson, AZ
Flight plan
IFR
Airport
LAX · Los Angeles International, runway 24L, 10,285 × 150 ft, concrete

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
56
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 1, 2009
Seat
Left
Flight hours
24,760 total · 20,993 in this make and model · 20,014 as pilot in command · 85 in the last 90 days · 4 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
37
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 15, 2009
Seat
Right
Flight hours
10,000 total · 2,000 in this make and model · 5,000 as pilot in command · 225 in the last 90 days · 75 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
240° at 10 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 50 °F
Altimeter
29.87 inHg
Observed at
LAX

Docket · 12

The files NTSB released with the investigation on March 19, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.6 MB in all.

FAA reports on this event · 1

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

Other investigations on N624SW · 1

Matched to the same aircraft by N-number and date.