NTSB Factual Report

On June 27, 2005, at 1818 Pacific daylight time a Boeing 727-230 transport category airplane, N357KP, lunged into a tug during engine start at the San Diego International Airport, San Diego, California. The airplane was operated by Capital Cargo International, Orlando, Florida, under the provisions of CFR Part 121 as a nonscheduled cargo flight. The captain, first officer, and flight engineer were uninjured, and there were no injuries sustained by ground crewmembers. The airplane was substantially damaged. The flight was originating at the time of the accident and was scheduled to stop in Denver, Colorado, before continuing to Toledo, Ohio. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight.

According to written statements obtained from the flight crew, the captain had written up the number 2 thrust reverser following the flight to San Diego because it required extra effort and movement to reach normal reverse thrust. Prior to the accident flight, the captain noticed that the number 2 throttle would not reach the full forward position and was approximately 2 inches aft of the number 1 and number 3 forward throttle positions. The captain called for maintenance to examine the throttle. The captain was informed that some final rigging steps had not been accomplished from the thrust reverser maintenance. The maintenance was completed and the aircraft was released for service. The flight crew informed maintenance that they would check the engines themselves after engine start, to which the maintenance personnel agreed.

Prior to engine start, the captain checked the throttle movement again, and noted that all of the levers reached the full forward position. When the captain moved the throttle levers back to idle, he thought he noticed the number 2 throttle spring forward a little, but after rechecking its movement, he was satisfied that the problem had been corrected.

The airplane was pushed back and the flight crew started the number 1 and 2 engines with no anomalies noted. They were in the process of starting the number 3 engine, when they heard a loud roar of an engine and felt the airplane lunge forward. The flight engineer announced the number 2 throttle was open and pulled the throttle lever to idle. The captain applied brake pressure and called for engine shutdown.

According to the captain, he did not notice the number 2 throttle move forward because he was looking at the ground crew for a brake signal. The copilot did not observe the number 2 throttle move forward because he was concentrating on starting the number 3 engine and examining the oil pressure gauges for the number 1 and 2 engines. The flight engineer indicated that he had not noticed the number 2 throttle movement because he was looking at his panel to confirm that the number 2 start valve had closed and the number 3 start valve had opened. He then monitored the oil pressure when he heard the engine spooling up to high power followed by the movement of the airplane.

According to a report provided by the San Diego Harbor Police Department, the flight crew would not provide a statement following the event. The flight crewmembers were tested for drugs and alcohol; all with negative results.

Mechanics examined the entire engine and throttle control rigging after the accident under the supervision of a Federal Aviation Administration San Diego Flight Standards District Office airworthiness inspector. The mechanics utilized the aircraft's maintenance manual to test the engine thrust control system. According to the mechanics and the airworthiness inspector, no anomalies were noted with the throttle's rigging. Subsequent engine runs were unsuccessful in duplicating the engine surge. The airplane was not equipped with an autothrottle system.

The cockpit voice recorder (CVR) and flight data recorder (FDR) were removed from the airplane and shipped to the NTSB's Vehicle Recorder Laboratory in Washington, D.C. for further examination.

A Fairchild model A-100A CVR, s/n 57927, was delivered to the audio laboratory of the National Transportation Safety Board on July 1, 2005. The recorder was in good condition and the audio information was extracted from the recorder normally, without difficulty. A CVR group was not convened and a detailed verbatim transcript was not prepared as it was determined that a summary of the event contained on the CVR recording was insufficient to support the investigation. The 32:18-minute recording consisted of four channels of good quality audio information. The recording did not contain any information during the pushback or ground collision. The recording started at an unknown time after the event and engines had been shut down. The voices heard were two crewmembers discussing the securing of the aircraft. During the recording, there were several interruptions in aircraft power. Later in the recording, several mechanics were performing some operational checks.

NTSB Probable Cause

the inadvertent throttle movement by one of the flight crew and the captain's inadequate supervision during the engine start sequence.