Pilot Debrief

BOEING 757-222 near Los Angeles, CA — 2011-05-31

Final reportWPR11LA300
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Date
2011-05-31
Location
Los Angeles, CA, USA
Airport
LAX
Aircraft
BOEING 757-222
Registration
N526UA
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Ground

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.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Flight crew should not have released parking brakes as per company manual.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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