WPR11LA300

NTSB accident investigation · Boeing 757-222 · Los Angeles, CA · May 31, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
May 31, 2011, 12:15 local (19:15 UTC)
Place
Los Angeles, CA
Injuries
1 serious, 190 uninjured; on the ground: 1 serious
Damage
Minor damage
Phase of flight
Pushback/towing
Aircraft
N526UABoeing 757-222
Defining event
Pushback/tow-engine not oper: Ground handling event
Weather
Visual (VMC) · Day
Status
Completed · report November 7, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, United Airlines
FAA report
20110531013149A
Case key
80953

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 crewmembers’ failure to follow proper procedures for removing a stuck or jammed tow bar, which resulted in a ground crew injury.

Findings · 1

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.

Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Ground crewBoeing 757-222: 1 caseAll 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.

Analysis

The tug’s tow bar’s shear pins broke while the airplane was being pushed back from the gate to an adjacent alley (a “turn reversal”), which required a significant (but within limits) turn of the nose landing gear. The tow bar became stuck and, despite repeated attempts by the operator’s ground crew personnel, would not disconnect from the tug or the airplane. When the operator’s ground personnel asked the pilots to release the airplane’s parking brake to ease the tension on the tow bar, the pilots did so. The airplane rolled slightly forward, contacting and fracturing the foot of one of the ground crewmembers. Although the operator’s ground crew ramp service manual procedure and flight manual guidance specified that the airplane’s parking brakes should not be released to assist in releasing a stuck tow bar, the pilots stated that they released the brakes believing that they were going to resume pushback. As a result of a postaccident hazard assessment, the operator stopped performing turn reversal tow operations similar to the accident operation.

Factual narrative

On May 31, 2011, about 1215 Pacific daylight time, a Boeing 757-222, N526UA, operating as flight number 840, was being pushed back from the gate at the Los Angeles International Airport (LAX), Los Angeles, California, when, one of its nose wheel tires made contact with and trapped a ground crewmember's foot. The airplane's nose gear tire sustained minor damage while the ground crewmember sustained a serious foot injury. United Airlines was operating the domestic passenger flight from Los Angeles to Chicago, Illinois, under the provisions of Title 14 Code of Federal regulations Part 121. There were 182 passengers on board, along with six cabin crewmembers and two airline transport certificated pilots. Representatives from United Airlines reported the accident occurred as the airplane was being turned to a nose out position in the alley, adjacent to the dispatch gate. The tow bar's shear pins broke during the turn, and additional ground personnel arrived on scene to assist in removing the tow bar and its respective pins. The position of the tow bar was about at an 80 degree angle, but not past the limit, as marked on the airplane nose landing gear door. The flight crew was requested to set the brakes and attempts to release the tow bar from the tractor and airplane were initially unsuccessful. Proper company tow bar removal procedures for abnormal conditions were not referenced by ground personnel during these efforts. In an attempt to relieve tension on the tow bar, ground personnel requested the flight crew to release the parking brakes. Although, the company flight manual has a caution for flight crews not to release the parking brakes to assist in releasing a stuck tow bar, the flight crew complied with the ground crew’s request. The flight crew assumed they were resuming the pushback since they were not made aware of any difficulty in removing the tow bar. The airplane brakes were released while ground personnel attempted to release the tow bar. Attempts to open the locking handle on the tow bar were successful and the tow bar immediately dropped to the ramp. The airplane rolled slightly forward and overran the tow bar and then made contact with and trapped one of the assisting ground personnel's foot before coming to a stop. Post accident inspection revealed no mechanical discrepancies in the airplane braking system.

Aircraft

Registration
N526UA
Reported as
Boeing 757-222
Category
Airplane
Serial number
24994
Airframe hours
67,211
Engines
P & W PW2040, 40,900 lbs thrust, turbo fanP & W PW2040, 40,900 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
United Airlines
Registered owner
Wells Fargo Bank Northwest Na Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · May 23, 2011
Departed
LAX · Los Angeles, CA
Destination
ORD · Chicago, IL
Flight plan
IFR
Airport
LAX · Los Angeles Intl.

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
52
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
March 1, 2011
Seat
Left
Flight hours
11,829 total · 4,810 in this make and model · 3,445 as pilot in command · 88 in the last 90 days · 45 in the last 30 days · 7 in the last 24 hours
Role
Co-pilot
Age
47
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
May 1, 2011
Seat
Right
Flight hours
10,064 total · 1,794 in this make and model · 2,399 as pilot in command · 236 in the last 90 days · 69 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None

Docket · 8

The files NTSB released with the investigation on September 12, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 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 N526UA · 2

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