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NTSB Report

September 6, 1995 · Boeing 737-4Q8 · N405KW

Miami, FL

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
September 6, 1995
Injury Outcomes
No injuries (78 uninjured)
Location
Miami, FL
Aircraft
Boeing 737-4Q8
Tail Number
N405KW
Operator
Carnival Air Lines
Injuries
None
Aircraft Damage
Substantial
NTSB Number
MIA95LA218

A GROUND SUPPORT EMPLOYEE WAS ATTEMPTING WITHOUT ASSISTANCE TO CONNECT THE TOWBAR TO THE PAYMOVER TO PUSH BACK THE AIRPLANE FROM THE GATE. THE PAYMOVER REPORTEDLY MOVED UNCOMMANDED REARWARD AND COLLIDED WITH OTHER GROUND EQUIPMENT. THE ENGINE OF THE PAYMOVER WAS SHUT DOWN AND A GROUND SUPPORT SUPERVISOR BOARDED THE PAYMOVER TO AGAIN ATTEMPT TO PUSHBACK THE AIRPLANE. THE SUPERVISOR STATED THAT WHILE STANDING ON THE PAYMOVER WITH THE PARKING BRAKE RELEASED AFTER STARTING THE ENGINE, THE PAYMOVER MOVED UNCOMMANDED FORWARD. ATTEMPTS TO STOP IT WERE UNSUCCESSFUL. THE PAYMOVER COLLIDED WITH THE TOWBAR THEN WITH A GROUND POWER UNIT WHICH WAS PUSHED INTO THE FUSELAGE. THE NORMAL BRAKE SYSTEM WHICH WAS NOT REPAIRED AFTER THE ACCIDENT WAS OPERATIONALLY TESTED AFTER THE ACCIDENT; NO DEFECTS WERE NOTED. OPERATIONAL TEST OF NEUTRAL SAFETY SWITCH COULD NOT DUPLICATE THE MALFUNCTION. SIMILAR DISCREPANCIES REGARDING UNCOMMANDED MOVEMENT OF THE PAYMOVER WERE REPORTED.

NTSB Probable Cause

IMPROPER PLANNING/DECISION BY THE COMPANY DRIVER OF THE VEHICLE (PAYMOVER) AND UNCOMMANDED MOVEMENT OF THE PAYMOVER FOR UNDETERMINED REASONS.

Full Narrative

On September 6, 1995, about 1220 eastern daylight time, a Boeing 737-4Q8, N405KW, registered to International Lease Finance Corporation, operated by Carnival Air Lines, Inc., was substantially damaged while attempting to push back from a gate at the Miami International Airport, Miami, Florida. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed for the 14 CFR Part 121 scheduled, international, passenger flight. The captain, first officer, cabin crew of 4, and 72 passengers were not injured. The flight was originating at the time of the accident. An employee of the company that provides ground support stated that the towbar was first connected to the airplane. He then positioned the paymover and attempted without assistance to connect the towbar to the paymover. The paymover then moved uncommanded rearward and collided with a container loader. The engine of the paymover was then shut down and the captain and a ground support supervisor who were on the flight deck inspected the airplane for damage; none was noted. The captain returned to the flight deck and the supervisor boarded the paymover. The supervisor stated that while standing on the paymover he disengaged the parking brake, applied the normal brakes, and started the engine of the paymover. Immediately after the engine was started the paymover moved uncommanded forward and attempts to stop the paymover using the normal brakes were unsuccessful. The paymover then collided with the towbar and a ground power unit which was pushed into the fuselage. The supervisor further stated that he operates similar paymovers daily. Following the accident, damage to the tug was repaired; however, the normal brake system of the tug was not worked on. The neutral safety switch which is designed to prevent starting of the engine with the transmission in drive or reverse was operationally checked for failure or malfunction, with no defects noted. Additionally, postaccident operational testing of the normal brakes at near full acceleration revealed no evidence of failure or malfunction. According to the cargo manager, the paymover involved in the accident had been in the shop for maintenance on August 28, 1995, and during testing, the engine started once while the transmission selector was in the "drive" position. Attempts to duplicate were unsuccessful. The paymover was returned to service. According to the training manager he experienced a similar occurrence involving uncommanded movement of the same paymover but the normal brakes stopped the paymover. He also stated that discrepancies with ground support equipment are verbally reported to maintenance. Review of maintenance work orders for the accident paymover from March 1994, to the date of the accident revealed no similar discrepancies.

Flight

Event TypeAccident
Event Time12:20 EDT
Nearest AirportMiami International (0nm)
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBoeing 737-4Q8
Tail NumberN405KW
Aircraft CategoryAir
DamageSubstantial
OperatorCarnival Air Lines
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsCfm · CFM-56-3C-1 · Turbofan · 22500
Seats167

People & Injuries

Injury SummaryNo injuries (78 uninjured)
Fatal0
Serious0
Minor0
Uninjured78
Total78
Crew 1Age 39 · First Class

Conditions

ConditionsVMC
LightDaylight
Wind130° @ 7 kt
Visibility7 sm
CeilingBroken clouds 25000 ft
Altimeter29.00 inHg
Observation Time15:50
Weather SourceWFAC

Appendix: Source Data