NTSB Factual Report

HISTORY OF FLIGHT

On September 12, 2003, about 1915 eastern daylight time, a McDonnell Douglas DC-9-51, N776NC, operated by Northwest Airlines (NWA) as flight 1569, received minor damage during pushback from Gate 30, when it was struck by a pushback tractor at the Norfolk International Airport (ORF), Norfolk, Virginia. The 2 flightcrew members, 3 flight attendants, and 36 passengers were not injured; however, the pushback tractor driver was fatally injured. Night visual meteorological conditions prevailed, and an instrument flight rules flight plan had been filed for the flight that was destined for the Memphis International Airport (MEM), Memphis, Tennessee. The scheduled passenger flight was conducted under 14 CFR Part 121.

According to the captain of flight 1569, the airplane was standing at Gate 30, with passenger boarding still in progress. The flight was scheduled to depart at 1930. After completing the preflight checklist, the flightcrew felt a "thump" under the airplane. Since no communication had been established with the ground crew, the captain sent the first officer outside the airplane to assess if there was any damage to the airplane. The first officer observed that the pushback tractor had struck the radome, and that the driver of the pushback tractor was trapped between the pushback tractor and the airplane. The first officer also noted that the ramp area was dry.

A NWA ground operations employee was approaching the right side of the airplane on a baggage tug to load "last minute" baggage. As he neared the airplane, he saw the pushback tractor driver positioning the tractor towards the nose of the airplane to connect the tractor to the towbar, which was attached to the nosegear. The ground operations employee looked away, until he heard a "loud noise" and saw the towbar attached to the airplane "buckle up and [go] into the air." He realized something was wrong, and immediately went to the nose of the airplane, where he observed the pushback tractor "going directly into the… aircraft." He did not notice whether the driver was sitting or standing in the tug, or whether she was looking forward or backward, as the tug collided with the aircraft.

AIRPORT INFORMATION

The ramp conditions at the time of the accident were dry and well illuminated. The above-referenced NWA ground operations employee said that he had utilized the pushback tractor earlier during the day, and recalled it functioned normally.

PERSONNEL INFORMATION

According to NWA, training for the operation of the pushback tractor was under the supervision of the Virginia State Occupational Safety and Health (OSHA) plan and NWA policy, which required one-time, formal training on the safe operation of Powered Industrial Trucks (PIT). Also required was a three-year recurring practical evaluation of operational safety. All training conducted by NWA was to be documented and recorded in a computer-based program.

The training received by the pushback tractor driver, as it related to the proper use of tractors and towbars, was "hands-on type training," and no specific guidance was provided in the operator's Ground Operations Manual.

Review of records by NWA indicated that the pushback tractor driver had received computer-based Powered Industrial Truck (PIT) training in April 2003, while working at the NWA Detroit Airport facility.

The last documented date the driver received specific operational training on pushback operations was in 1992.

Review of training records kept at ORF by an FAA inspector, revealed no documents that indicated the pushback tractor driver had any training, qualifications, or authorization regarding pushback procedures.

According to a NWA Certified Instructor for ORF, he had not conducted aircraft pushback training to ORF employees for approximately two years. He also stated that he never provided any training to the pushback tractor driver involved in the accident.

Review of ORF station records by NWA revealed that the pushback tractor driver had worked a total of 191.2 hours in the thirty days prior to the accident. Of the prior 30 days, the actual days worked were 22 days, with 8 being off duty. The driver was scheduled off duty on September 8 and 9 and worked 8-hour shifts on September 10 and 11.

On the day of the accident (September 12), the driver was assigned to baggage room duties for NWA flights 1447, 3571, and 1569. She reported for duty at 1200. The driver was not assigned, nor required, to operate the pushback tractor.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site by a Federal Aviation Administration (FAA) inspector revealed that the pushback tractor used to push back the airplane had an open-air type cab at the front of the chassis, with no roll bar. The pushback tractor came to rest about 4 feet under the nose of the airplane. A gash was noted on the left section of the red painted front bumper of the pushback tractor, which extended from the hookup pin area, outwards. A red paint transfer mark was observed on the outer face of the towbar connection ring. The inspector also noted a towbar remained connected to the airplane's nose wheel assembly, and was rotated to the right at an approximate 45-degree angle. When the airplane's nose wheel assembly, along with the connected towbar, was rotated to a forward position, the towbar extended beyond the nose of the airplane by only 1 foot.

The pushback tractor was equipped with a diesel engine and an automatic transmission with positions for reverse, neutral, and forward drive: "1, 2, 3, and D." The tractor was also equipped with accelerator and brake pedals, and a manual parking brake.

The pushback tractor was not equipped with any rearward facing mirrors to assist in towbar hookup operations.

Additional employees at ORF stated that they had utilized the pushback tractor the day of the accident, and reported no abnormalities with its operation.

According to a representative of NWA, the pushback tractor was inspected after the accident. No anomalies were noted with the operation of the pushback tractor.

ADDITIONAL INFORMATION

Staffing Information.

According to NWA, the ORF facility's staffing level for the day of the accident (4 employees), while less than usual, was consistent with the company's approved staffing model.

Pushback Procedures Information.

In a follow-up interview conducted by NWA and forwarded to the Safety Board, the ground operations employee that was working NWA flight 1569 stated that the pushback tractor driver had previously informed him that she was trained on airplane pushback procedures at NWA's Detroit Airport facility, but he had never observed her operate the pushback tractor at ORF. The ground operations employee also did not recall ever instructing the pushback tractor driver to operate the pushback tractor at ORF.

According to NWA, two additional employees who worked flight 1569 the day of the accident stated that the connection of a towbar to a pushback vehicle was a single person procedure.

At the time of the accident, NWA did not have any written guidance outlined in the Ground Operations Manual for connecting a towbar to a pushback vehicle. The Ground Operations Manual did state, "Use caution when working in vicinity of aircraft. There is very low clearance between the aircraft and the ground."

After the accident, NWA issued additional guidance for connecting the towbar to pushback vehicles. The guidance required two employees to perform the procedure, one to drive the pushback vehicle, and one to provide hand signals and make the hookup connection. The guidance also detailed procedures for connecting the towbar to the pushback tractor.

Postaccident Pushback Tractor Modifications.

As a result of the accident, NWA used another pushback tractor at Norfolk that was equipped with a protective enclosure over the driver cab, and NWA planned to make modifications to the rest of its pushback tractor fleet by installing protective barriers over the tug cab.

( This case was modified on October 5, 2006 )

NTSB Probable Cause

the airline ground person's failure to properly control the pushback tug, and her subsequent failure to maintain adequate clearance between the tug and the airplane. Factors contributing to the accident were the airline ground person's operation of the tug without qualification or authorization, and the lack of a protective enclosure over the tug's cab.

( This case was modified on October 5, 2006 )