NTSB Factual Report

On November 2, 2010, at 1027 central daylight time, a Bombardier CL-600-2B19, N709BR, operated by SkyWest Airlines as flight 1020, was struck by an unoccupied United Airlines pickup truck at the O'Hare International Airport (ORD), Chicago, Illinois. There were no injuries to the 2 cockpit crew members, 1 cabin crew member, and 34 passengers. The airplane sustained substantial damage to four stringers and the forward bulkhead. The flight was operating under 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed and an instrument flight rules flight plan had been filed. The planned destination for the flight was Quad City International Airport (MLI), Moline, Illinois.

The airplane had pushed back from gate F2 and stopped on the ramp when the crew was informed that they were blocking a gate. As the crew began to move the airplane they saw the pickup truck moving "rapidly" in reverse on the ramp, so they stopped. The pickup truck, which was unoccupied, then impacted the left side of the nose of the airplane.

The pickup truck was previously driven to the terminal building at gate F2D. The driver stated that he put the truck in park, and exited the truck with the engine running. He stated he was only going to be a short time, so he did not think it was necessary to turn the ignition off. He also stated that he did not apply the parking brake. When he returned to where he left the truck, it was gone. The driver stated he then saw the truck under the nose of the airplane.

Surveillance cameras at ORD captured the accident from two different vantage points. The videos both show the airplane stopped on the ramp between the F and G concourses. The blue pickup truck then crossed the ramp from right to left heading toward the F concourse prior to it going out of view. Approximately 18 seconds later, the truck can be seen backing away from the terminal building. The video revealed that the truck crossed about 100 to 150 feet in front of the airplane. While still traveling in reverse, the truck made a 180 degree turn and headed toward the airplane. The airplane stopped just prior to the impact with the pickup truck.

According to United Airlines personnel, other than turning off the ignition, nothing was changed inside the truck after the accident. Photographs taken at the accident site show the gear shift lever was positioned between P (park) and R (reverse).

The truck was towed from the accident site for a postaccident inspection. The truck was a 2001 Ford Ranger standard cab pickup which was owned and operated by United Airlines. The United Airlines identifier for the truck is PI1574. The truck odometer reading was 35,211 miles and the United Airlines hour meter installed in the truck indicated 3,816.7 hours.

The truck was hoisted off the ground for the initial inspection and testing. The gear shift lever remained as it was found; between park and reverse. When the ignition key was turned on the rear wheels could be turned by hand, the back-up lights were not illuminated, and the engine could not be started, indicating the truck was not in park. The gearshift lever was moved toward the parked position and after several attempts, the transmission went into park, locking up the drive train and allowing the engine to be started.

The truck was then lowered to the ground and the engine was started. The vehicle was driven a short distance and stopped. The gearshift lever was moved to park, and the brakes were released. The vehicle remained stationary for 2 to 3 seconds then it began to move in reverse. This occurrence was repeated several times.

The shift cable adjustment procedure as outlined in the 2001 Ford Ranger Service Manual was performed. Following the procedure resulted in a 3/16 of an inch adjustment to the shift cable length. Following the adjustment the transmission functioned reliably in park, reverse, neutral, and drive, but could not be placed in either 1st or 2nd.

The inspection also revealed the parking brake cable was disconnected where the cable splits from one actuating cable to two, one for each rear wheel. The inspection also found that the right front tire was excessively worn along its inside edge.

The pickup truck driver, a United Airlines employee, stated that he performed a user check on the truck which consisted of starting the engine, and checking the brakes and lights. He added that the vehicle was operational and that he had driven it earlier in his shift. The driver said that to his knowledge there was nothing wrong with the gear shift lever. He stated that employees were not required to perform user checks on the vehicles at the beginning of their shift. He also stated that it was standard operating procedure to leave the vehicles running in the winter and that the proper way to park a vehicle outside the terminal was to back the vehicle in toward the building.

United Airlines Ground Equipment PM Program Detail and Task List states that ground vehicles must undergo a B Check every 12 months or 500 hours. It also states, "Safety items found during preventative maintenance will not be deferred. Work and repair items must be accomplished before equipment is returned to service and must be recorded on a separate work order." Among the items listed on the B check are:

• Shifter must lock into detent

• Unit must not move when shifter is in park or neutral

• Parking brake must hold in drive while idling

According to work order 7431, the last B check on the truck was completed on April 26, 2010. The meter reading at that time was 3,233.0 hours, 583.7 hours prior to the accident. Comments listed on the work order were "B/CK/COMPLETE." Work order 6095 listed the items that were addressed during the B check. Items listed on work order 6095 were:

• Bad brakes/Replace rear brakes-replace wheel cylinders-bleed and

adjust

• No start-weak battery/Replace battery-drill out old broken hold

down bolt

• Upper and lower ball joints bad-both sides/remove

spindles/Replace upper control arms

• Stabilizer link broke/Replace both links

• Tires worn/Replace tires

• Spark plugs worn/Replace plugs

• Front brakes worn/Replace pads-rotors-pack bearings

• Rear brake cables froze/replace rear cables

• Right front corner light inop/Remove headlight assy/Replace bulb

• Upper brake light inop/Replace bulbs

• Cut Drums and inspect....Complete

UNITED AIRLINES RAMP OPERATIONS MANUAL

United Airlines Ramp Operations Manual addresses the operation of their ground vehicles. Page 8.1.2 of the manual states, in part:

Park motorized equipment, not in use, in designated areas.

- Place the unit in neutral;

- Set the parking brake;

- Turn lights off;

- Lower or stow platforms and booms; and

- Turn off the engine or electric power.

Under the Anti-Idling Policy it states:

• No motorized vehicle shall be left running while unattended.

Pages 8.1.3 and 8.1.4 of the manual address User Checks. This section states, in part:

Motorized Equipment

Check motorized equipment units at least once a shift. Keep local records of these checks for at least one month. Note: When equipment is not used on a daily basis or when equipment was not in use during the previous shift, it must be checked before returning it to service.

Brakes

Check primary brakes for pedal travel and to ensure the pedal has a non-slip foot pad.

Check parking brake for holding action. Check with the engine running at idle speed by placing the unit in both forward and reverse gears.

Tires

Check visually for proper inflation and sufficient tread.

Controls/Shift Quadrants

Check for excessive wear on the plate, looseness of control handle and placards.

O'HARE INTERNATIONAL AIRPORT PROEDURES

The Chicago Airport System, Ground Motor Vehicle Operation Regulations Manual, is the operations manual for those who operate ground vehicles in the airport operations area. The manual states, in part:

11. OPERATIONS NEAR AIRCRAFT

C. When on the airfield, all vehicles must back into designated parking area, including spaces adjacent to and perpendicular to buildings.

12. VEHICLE OPERATION ON THE AIRFIELD

H. No vehicle will be left unattended with its motor running, unless weather or operational conditions dictate otherwise.

19. SAFETY EQUIPMENT

B. Ground Vehicle Brakes

2. All vehicles must be equipped with a properly functioning parking brake. In the event a vehicle operator must leave their vehicle unattended, they must engage the parking brake.

Persons approved to operate drive vehicles within the airport operation area are required to be tested on the information in the Chicago Airport System, Ground Motor Vehicle Operation Regulations Manual. The truck driver passed the test on November 21, 2008.

As a result of this accident, United Airlines conducted an inspection off all their ground vehicles at ORD. The inspection resulted in 8 out of 111 vehicles being taken out of service for repairs. In addition, United Airlines instituted the following changes:

1) Developed a service vehicle user check audit program at ORD.

2) Developed a user check audit program at ORD to ensure compliance with company policy of performing user checks on ground service vehicles.

3) Instituted a Maintenance Management Program (MMP) to analyze what service vehicle parts are failing and at what frequency. The objective is to replace parts prior to them failing.

4) Created a Maintenance Planner position to track and monitor the maintenance program for ground service vehicles, and to assure maintenance is being done in a timely manner.

5) All ground vehicle user checks at ORD were reviewed and revised as needed.

6) Continual evaluation of area to park and store ground service vehicles.

7) Directed all United Airline ORD departments to enforce the policy of setting the parking brake whenever a vehicle is left unattended.

NTSB Probable Cause

The pickup truck driver’s failure to follow airport and company policies regarding ground vehicle operations, which allowed for the unattended truck to collide with the airplane. Contributing to the accident were the truck's misadjusted shift lever and disconnected parking brake.