Investigation Summary
The accident occurred during the morning pushback of a USAir Boeing 737-300LR. The ground crew consisted of two members: a tug driver and a walker. The walker was connected to the aircraft via a 15 foot communication cord, a length that investigators determined restricted his ability to stay clear of the nosewheel, towbar, and tug. While the tug was in motion, the walker fell for unknown reasons. The tug driver, seated on the left side of the vehicle, saw the fall and initiated an immediate stop, but the momentum of the tug resulted in a fatal strike. Investigation into company safety culture revealed that although a maintenance training bulletin regarding nosewheel clearance had been issued in December 1989, it was not mandatory reading and its requirements had not been integrated into the General Maintenance Manual.
Final Conclusions
The National Transportation Safety Board determined the probable cause was the lack of adequate clearance between the walker and the tug, which led to the walker being struck after falling for unknown reasons. A contributing factor was the operator's lack of a formal policy requiring personnel to stay clear of the tug, towbar, and nosewheel while pushback operations were in motion.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Pilot-in-command had 5,000 hours of PIC time and 67 hours in the last 30 days.
Systems & Failure Modes
Pushback Tug
A ground vehicle used to move the aircraft backward from the gate; in this instance, it struck the walker after he fell into its path.
Communication Headset
A wired system allowing the ground walker to communicate with the flight deck; the 15 foot cord length was cited as a factor in restricting the walker's movement.
Interesting Facts
- 01The walker was using a 15 foot headset cord which limited his movement away from the tug and nosewheel.
- 02No witnesses were able to identify the specific reason why the walker fell.
- 03The tug driver was seated on the left side of the tug during the operation.
- 04The aircraft sustained no damage during the incident.
- 05A 1989 safety bulletin regarding ground clearance was not mandatory reading for the crew involved.
Safety Actions & Advisories
Integration of Safety Bulletins
Source ↗Following the investigation, it was noted that a 1989 maintenance training bulletin regarding nosewheel clearance had not been integrated into the General Maintenance Manual. The operator was encouraged to ensure such safety requirements are formalized in mandatory manuals.
Location
NO VERIFIED COORDINATES · Coordinates are the estimate published in the ntsb final report. No map is shown, because a marker here would imply a precision the record does not have.
Reported location: FLUSHING, New York