Event DCA24LA034

Factual narrative

HISTORY OF FLIGHTOn November 30, 2023, about 0614 Hawaii standard time (HST), a Boeing 717-200, N494HA, operated by Hawaiian Airlines as flight 105, sustained minor damage when it was involved in an incident while taxiing for departure at Kahului Airport (OGG), Maui, Hawaii. The 119 passengers and crew onboard were uninjured. One ramp worker sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 121 scheduled domestic passenger flight from OGG to Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii. The airplane was being pushed back from the gate before departure by three ground crew personnel, which included a tow tractor (tug) operator assisted by two wing walkers. One of the wing walkers was designated as an “escort,” whose responsibilities included disconnecting the tow bar from the airplane. The flight crew reported that they discussed the weather as the passengers boarded, describing it as “dicey” the morning of the incident, with low cloud ceilings and visibility, rain, and thunderstorms moving through the area. It was dark at the time, and the airplane’s windshield wipers were on. Both flight crewmembers recalled receiving the load closeout via ACARS (aircraft communication addressing and reporting system) during the pushback. Also during the pushback, the captain performed a manual start of the number one (left) engine, after which he set the brakes and instructed the ground crew to disconnect the tow bar. While the first officer (FO) completed entering the relevant data from the load closeout and air traffic control clearance into the flight management system (FMS), the captain started the number two (right) engine and cleared the ground crew to disconnect, which allowed the escort to disconnect the tow tractor operator’s headset cable from the airplane and to remove the nose landing gear steering bypass pin. The tow tractor operator recalled that the escort removed the steering bypass pin, disconnected the headset interphone cable from the airplane, then stood near the passenger side of the tow tractor and displayed the pin for about two minutes. The escort reported that captains normally saluted him after he displayed the steering bypass pin, but he could not see the captain salute him on this occasion. He could see the captain moving around the cockpit and it appeared to him that the captain was performing instrument checks. The captain stated in a post incident interview that he saw one of the ramp agents display the pin and its ribbon overhead with both hands, and estimated that the tow tractor was seven or eight feet from the side of the airplane, with the escort standing on the far side of the tow tractor. He recalled that it was difficult to see outside due to the rain and the darkness. The FO stated that from his vantage point, the tow tractor was obscured by aircraft structure. The captain reported that, in practice, the escort would normally display the pin, the flight crew would salute, and the escort would salute in return. When asked whether he flashed the airplane’s taxi light during this exchange, he stated that they normally flashed the taxi light, but he did not during the incident pushback. He added that he was “saturated” in assisting the FO with “the numbers and the clearance.” The escort informed the tow tractor operator that he had not received a salute from the captain. The tow tractor operator recalled that she honked the horn to attempt to get the captain’s attention, then waved at the cockpit, but was unable to elicit a response. The tow tractor operator recalled that, upon seeing the cockpit light turn off, she realized that the airplane was about to taxi and informed the escort that they needed to leave the area. The escort began to run away from the airplane toward the gate, and the tow tractor operator put the tractor in gear and began to drive away from the airplane. The flight crew completed the after-start checklist and received a taxi clearance from the tower controller. The crew began the taxi; however, the left main landing gear impacted the tow bar and the left wing impacted the tow tractor cab, resulting in the cab collapsing. Airport fire and rescue responded to the scene and extricated the driver, who was transported to the local hospital for treatment. Airport surveillance video captured the incident sequence and indicated that the two wing walkers were in position on either side of the airplane, each holding lighted wands, when the tow tractor operator began pushback. About 25 seconds into the pushback, which lasted a total of 1 minute and 15 seconds, the wing walker on the airplane’s left side began walking toward a ground service vehicle near the gate, placed his wands in the driver’s seat area, then walked back toward the airplane. About 35 seconds into the video, the wing walker on the airplane’s right side approached the driver’s side area of another ground service vehicle. His wands also disappeared, and he began walking back toward the gate, out of view. After pushback and disconnect of the towbar, the white rear-facing lights illuminated on the tractor as the operator backed up. These lights then extinguished, and the operator drove the tractor forward toward the captain’s side of the airplane’s nose. The operator stopped the tow tractor, and the escort secured the towbar to the rear of the tow tractor. The tow tractor operator then drove forward and parked the tractor on the captain’s side of the airplane’s nose. Subsequently the video showed that the tractor’s headlights came back on after the tug came to a stop. The tow tractor’s headlights appeared to illuminate an area of pavement located behind the cockpit alongside the airplane’s left fuselage. The escort approached the passenger’s side door of the tractor (where they normally placed the headset cable after disconnecting it from the airplane) and remained standing near the passenger side of the tractor for about 1 minute 37 seconds. No lighted wands were visible. At 0614:28 (per the surveillance video), the airplane’s taxi light illuminated, and immediately afterward the airplane began to move forward. Two seconds later, the escort could be seen running away from the airplane toward the gate. The tow tractor began to move forward toward the approaching left wing of the airplane. About nine seconds later, the airplane’s left wing impacted the tow tractor. PERSONNEL INFORMATIONCaptain The captain, age 29, held an airline transport pilot certificate with a multi-engine land rating, commercial pilot privileges for airplane single-engine land, and type ratings on the B-757, B-767, and DC-9. He held an FAA first-class medical certificate dated March 8, 2023, with the limitation, “Must use corrective lens(es) to meet vision standards at all required distances.” The captain stated that he was wearing corrective lenses at the time of the incident. The captain was hired by Hawaiian Airlines on June 1, 2022, and had accumulated about 3,300 hours total flight time, about 1,200 hours of which were in the B-717. First Officer The FO, age 35, held an airline transport pilot certificate with a multi-engine land rating, commercial pilot privileges for airplane single-engine land, and type ratings on the CL-65 and DC-9. He held an FAA first-class medical certificate dated November 3, 2022, with no limitations. The FO was hired by Hawaiian Airlines on April 18, 2023, and had accumulated about 2,000 hours total flight experience, about 233 hours of which were in the B-717. AIRCRAFT INFORMATIONAccording to the dispatch release for the incident flight, the airplane had two minimum equipment list (MEL) items. The MEL items were M33-41-01E “wing landing light extend/retract system light retracted” issued November 29, 2023, at 2231 HST, and M80-11-03, “auto starter control system” issued November 29, 2023, at 0751 HST. The wing landing light had been secured by maintenance and the MEL required no flight crew action. The No. 1 engine MEL item required the flight crew to perform a manual start on the No. 1 engine. The captain reported in a postincident interview that he reviewed the manual start procedure in the Quick Reference Handbook (QRH) and Flight Crew Operating Manual (FCOM). The expanded checklist for a manual engine start procedure in the FCOM specified that, because auto abort protection was not available during a manual start, the crew was required to monitor engine parameters for start exceedances and abort the start in the event of an exceedance. METEOROLOGICAL INFORMATIONOn the day of the incident, dawn was at 0621:31 and official sunrise was at 0645:06. The sun was 7.73° below the horizon at the time of the incident, and the captain reported that it was dark and raining. AIRPORT INFORMATIONAccording to the dispatch release for the incident flight, the airplane had two minimum equipment list (MEL) items. The MEL items were M33-41-01E “wing landing light extend/retract system light retracted” issued November 29, 2023, at 2231 HST, and M80-11-03, “auto starter control system” issued November 29, 2023, at 0751 HST. The wing landing light had been secured by maintenance and the MEL required no flight crew action. The No. 1 engine MEL item required the flight crew to perform a manual start on the No. 1 engine. The captain reported in a postincident interview that he reviewed the manual start procedure in the Quick Reference Handbook (QRH) and Flight Crew Operating Manual (FCOM). The expanded checklist for a manual engine start procedure in the FCOM specified that, because auto abort protection was not available during a manual start, the crew was required to monitor engine parameters for start exceedances and abort the start in the event of an exceedance. WRECKAGE AND IMPACT INFORMATIONA postincident examination of the airplane revealed minor damage to the left wing. ADDITIONAL INFORMATIONTow Tractor The tow tractor was a TMX-350 manufactured by TLD. See figure 2 for an example of an exemplar model tow tractor. According to manufacturer information, the tow tractor was designed to perform push and pull operations for up to 300 tons. The TMX-350 gross weight was between 53,000 lbs and 61,600 lbs depending on the model. It featured a Cummins QSB4.5 4-cylinder turbo diesel engine, with a powershift transmission with torque converter. The maximum speed when empty was 15 mph forward and 3 mph in reverse. The event model had only front wheel hydraulically-powered steering. The 24-volt DC electrical system powered 10 items of which front head lights, rear LED lights, stop LED lights, flashing beacon and hazard lights were among those items. Figure 2. Exemplar tow tractor. Note that the exemplar vehicle in this photo does not have a front hitch with a 2.7 diameter tow pin, nor a rotating yellow beacon mounted on the roof of the cab, both of which the event tow tractor had. (Source: Aero Specialties – a dealer of TLD tractors - Web Site) A rotating wand allowed the operator to turn the tow tractor’s headlights on and off, and a button on the tip of the wand activated the vehicle’s horn. A dashboard rocker switch panel allowed the operator to turn on or off the front and rear tow pin spotlights, front and rear wipers, rotating yellow beacon, and hazard lights (figure 3). An icon on each switch was illuminated by a blue light. When a switch was turned on, a green LED light embedded in the switch became illuminated. When the switch was selected off, the green LED light was extinguished. Figure 3. Switch panel on the dashboard of an exemplar tow tractor. In this photo, the front tow pin spotlight, rear tow pin spotlight, and rotating beacon are selected on. FAA guidance classifies pushback tractors as aircraft support vehicles and requires those that operate in the airport movement area to have a yellow flashing light mounted on the uppermost part of the vehicle structure. The yellow flashing light must be visible from any direction, day and night, including from the air. In addition, U.S. Department of Transportation Regulations pertaining to the state of Hawaii specify that, “Any vehicle proceeding onto the movement area between the hours of sunset and sunrise except those being escorted shall also operate an overhead flashing light which is visible for one mile.” The yellow flashing light is required to increase the conspicuity of ground vehicles in the airport movement area and to aid in their detection by flight crews and other vehicle operators. The incident tow tractor was equipped with a yellow flashing light mounted on its cab, as required. The tow tractor operator said that the light activated automatically when the tractor was “in motion” and deactivated when the tractor was “turned off.” She believed that the light was illuminated during the pushback. Further investigation of the tow tractor revealed that the yellow light would only illuminate if the tow tractor’s ignition was on and the light’s rocker switch (located on the dash) was also switched on. The position of the rocker switch was not documented immediately after the incident, and its position at the time of the incident could not be determined. The captain reported that he normally saw a rotating yellow light on top of the tow tractor, but could not recall a light being illuminated on the incident tow tractor. The airport surveillance video indicated that the incident tractor’s yellow beacon light was not illuminated during the pushback or at the time of the collision (see figure 4). Figure 4. Still image from surveillance video. During a night observation at OGG, investigators assessed the visibility of the tow tractor from the captain’s eye position inside the cockpit of a B717 when the tow tractor was parked in a location similar to that observed on the airport surveillance video. With the yellow beacon selected ON, the tow tractor was conspicuous in the investigator’s peripheral vision. With the beacon selected OFF, the tow tractor was low-contrast and difficult to see without focused visual attention. Hawaiian Airlines Procedures The HAL Ground Service Manual (GSM) contained guidance regarding ground personnel duties and responsibilities during pushback procedures. The GSM stated that a control service agent was responsible for the pushback of the airplane, which included operating the tow tractor and communicating with the flight crew. Additionally, two wing walkers were required to be in position, with one of those assigned as escort. The escort was responsible for connecting the towbar and assisting with connecting the tow tractor to the airplane, removing the towbar, removing the steering bypass pin, and notifying the flight crew, by displaying the pin and its flag, that the pin had been removed and that the airplane was released for taxi. Wing walkers were required to use high-visibility wands, paddles, or gloves for all signaling during daylight hours, and illuminated wands at night or in low visibility. The GSM stated that, after removing the steering bypass pin and being cleared to disconnect the communication headset, the control service agent was to move the tractor and towbar out of the path of, and facing away from the aircraft. The escort was to then ensure that personnel and equipment were in a safe area clear of the aircraft and await the “ready to taxi” signal (one flash of the airplane’s taxi light). Following the “ready to taxi” signal, the escort was to display the bypass pin flag, salute the flight crew, then board the tow tractor for transportation back to the terminal. In a post incident interview, the captain reported that he remembered calling for the after start checklist. The FO had finished verifying the weights from the load manifest, and he performed the after start checklist with the captain, which the captain estimated took five to ten seconds to perform. The after start checklist contained an item for “ground salute.” The FO was asked whether the captain saluted the ramp agent when the FO read this item, or whether the captain had already done so. The FO stated that he did not know whether the captain provided the salute, but he recalled that the captain provided the correct verbal response when he read the checklist item. The HAL Flight Operations Manual (FOM) stated that the escort should disconnect the steering bypass pin, display the pin flag, and “give the flight crew the procedure ending salute.” A separate table in the FOM stated that the escort should display the pin and issue a salute, and the flight crew should return the salute and flash the taxi light. Thus, the FOM contained conflicting information about the final communication. The GSM stated that, at all times, both the escort and service agent must be alert to potential hazards during engine start and be on the lookout for abnormal conditions. It stated that any abnormal indications must be communicated to the flight crew immediately. The GSM stated that, once “off headset,” the flight crew could re-establish communications with the ramp crew by flashing the taxi light three times; however, no such procedure was outlined for the ramp crew to re-establish communication with the flight crew after disconnecting the headset. The expanded checklist for the after-start procedure contained the following information regarding the load closeout: When possible, review the load closeout prior to taxi. If the load closeout has not been received by the completion of the after start checklist, taxi to the departure runway is allowed. However, the FOM requires this review to be completed prior to take off. Section 11.6 of the FOM, “Taxiing,” included: Prior to the start of taxi, the Captain shall visually check the left side of the aircraft and announce “Clear Left.” The First Officer shall visually check the right side of the aircraft and announce “Clear Right.” When the captain was asked if he looked out the left side of the cockpit and said “clear left” in accordance with the procedure, he stated, “I think I did say that…it was kind of dark out there. I don’t recall seeing anything on the left side.” Safety Actions Accidents involving ground service personnel were typically investigated by Hawaiian Airlines corporate airport operations safety, assisted by personnel from the affected station. A Hawaiian Airlines investigation of this incident was performed by two investigators from airport operations safety in cooperation with two airport operations managers from the Maui base (the base director and one operational manager). This investigation identified a lack of compliance with some operational procedures and a lack of clarity in company manuals. According to the senior manager for airport operations safety, the GSM specified that after the headset cable was disconnected, ground service personnel were supposed to relocate the tow tractor one wingspan from the fuselage and 45 degrees forward of the cockpit before they displayed the nosewheel steering pin. Hawaiian Airlines found that ground crews had been displaying the pin next to the cockpit and saluting the flight crew without first relocating the tug. Hawaiian Airlines determined that this practice, which the senior manager of airport operations described as evidence of “procedural drift,” could be addressed through clearer guidance and training. They subsequently issued an alert, began meeting with ground personnel at each base to discuss the existing procedure, and reviewed ground service training materials to see how they could be improved. The airport operations safety team also coordinated with the airline’s flight operations department to ensure that there was no discrepancy between the GSM and the FOM regarding coordination and communication between pilots and ground service personnel during pushback. The FOM (but not the GSM) stated that the flight crew was supposed to flash the taxi light before ground service personnel provided a salute and departed with the tug; however, this practice was not occurring consistently. FLIGHT RECORDERSFollowing the incident, the flight recorders were sent to NTSB Headquarters in Washington, D.C. The NTSB Vehicle Recorder Division received a Honeywell solid state flight data recorder (SSFDR) (Model 4700) and a Honeywell cockpit voice recorder (CVR) (Model HFR5-V). The recorders were in good condition and the data was extracted normally from the recorders. Flight Data Recorder The flight data recording contained approximately 27 hours of data. The event was the last movement of the recording, and its duration was approximately 22 minutes, with several gaps in the recording, see figure 1. A review of the flight data recorder (FDR) revealed that, starting at 0614:28, the airplane’s groundspeed increased from 0 to 8 knots, followed by a decrease in longitudinal acceleration from 0.05 to -0.56 gravitational force equivalent (g) before increasing to 0.04 g. At 0614:35 until 0614:41, the vertical acceleration oscillated from 1 g to a maximum of 1.29 g and a minimum of 0.68 g before settling back at 1 g for the rest of the data. Figure 1. Plot of FDR parameters from 1609:42 UTC to the end of the recording at 1631:55 UTC. Cockpit Voice Recorder The cockpit voice recorder (CVR) recorded a minimum of 120 minutes of digital audio stored on solid state memory modules. Four channels were recorded: one channel for each flight crew member, one channel for a cockpit observer, and one channel for the cockpit area microphone. All four channels had good to excellent quality audio and a summary was created of the audio associated with the incident. The CVR recording did not begin until after the collision, at 0622:48, and captured flight crew conversations about the event. Between 0624 and 0631, the captain made comments indicating that he didn’t think the tow tractor driver received a salute; that he thought he provided a salute but could not remember; and that he saw the tow tractor, but did not provide a salute. After pushing back from the gate, Hawaiian Airlines (HAL) flight 105, a Boeing 717-200, collided with a tow tractor while the flight crew was initiating their taxi for departure from Kahului Airport (OGG), Maui, Hawaii. The 119 passengers and crew onboard were uninjured. One ramp worker sustained minor injuries. The airplane sustained minor damage. The flight crew reported that, after obtaining pushback clearance from air traffic control, they released the airplane’s brakes and the tow tractor operator began to push the airplane back from the gate. The captain reported that it was dark outside and raining. Due to an inoperative engine auto starter, the captain was required to perform the manual engine start procedure. After successfully starting the No. 1 (left) engine, the captain set the brakes and instructed the ground crew to disconnect the tow bar. The captain stated that he then began a manual start of the No. 2 (right) engine. After the No. 2 engine was started, he cleared the ground crew to disconnect the headset interphone and the nose landing gear bypass pin. The captain recalled that he saw one of the ramp agents (the escort) display the pin and its ribbon overhead with two hands. He recalled giving the escort a salute in return, but was unsure if the escort saw the salute. The first officer (FO) reported that he could not see the escort or the tow tractor from his position, as they were obscured by aircraft structure. He also stated that he was heads-down looking at the flight management system (FMS) and did not see whether the captain saluted the escort. The tow tractor operator recalled that the escort removed the steering bypass pin, disconnected the headset interphone cable from the airplane (thereby removing a means of direct communication with the flight crew), then stood near the passenger side of the tow tractor and displayed the pin for about two minutes. The escort reported that captains normally saluted him after he displayed the steering bypass pin, but he could not see the captain salute him on this occasion. He could see the captain moving around the cockpit and it appeared to him that the captain was performing instrument checks. The escort informed the tow tractor operator that he had not received a salute from the captain. The tow tractor operator recalled that she honked the horn to attempt to get the captain’s attention, then waved at the cockpit, but was unable to elicit a response from the captain. The flight crew’s after-start checklist included an item for “ground salute.” The FO stated that he did not know whether the captain provided the salute, but the captain did provide the proper response to the checklist callout. The FO requested and received a taxi clearance from air traffic control and the captain turned off the cockpit dome light in preparation for taxi. The tow tractor operator recalled that, upon seeing the cockpit light turn off, she realized that the airplane was about to taxi and informed the escort that they needed to leave the area. The escort began to run away from the airplane toward the gate, and the tow tractor operator put the tractor in gear and began to drive away from the airplane. Shortly after beginning the taxi, the crew felt an unusual motion as the airplane’s left main landing gear impacted the tow bar and the left wing impacted the tow tractor cab. When the captain was asked if he looked out the left side of the cockpit and said “clear left” in accordance with the airline’s flight operations manual (FOM) procedure, he stated, “I think I did say that…it was kind of dark out there. I don’t recall seeing anything on the left side.” Hawaiian Airlines Guidance During Pushback HAL Ground Service Manual (GSM) provided guidance regarding ground personnel duties and responsibilities during pushback procedures. The GSM stated that a control service agent was responsible for the pushback of the airplane, which included operating the tow tractor and communicating with the flight crew. Additionally, two wing walkers, equipped with illuminated wands for signaling during night operations, were required to be in position, with one of those assigned as escort. The escort was responsible for connecting the towbar and assisting with connecting the tow tractor to the airplane, removing the towbar, removing the steering bypass pin, and notifying the flight crew, by displaying the pin and its flag, that the pin had been removed and that the airplane was released for taxi. The GSM stated that, after removing the steering bypass pin and being cleared to disconnect the communication headset, the control service agent was to move the tractor and towbar out of the path of and facing away from the aircraft. The escort was to then ensure that personnel and equipment were in a safe area clear of the aircraft and await the “ready to taxi” signal (one flash of the airplane’s taxi light). Following the “ready to taxi” signal, the escort was to display the bypass pin flag, salute the flight crew, then board the tow tractor for transportation back to the terminal. The FOM stated that the escort should disconnect the steering bypass pin, display the pin flag, and “give the flight crew the procedure ending salute.” A separate table in the FOM stated that the escort should display the pin and issue a salute, and the flight crew should return the salute and flash the taxi light. Thus, the FOM contained conflicting information about the final communication. The captain stated that the procedure was for the escort to display the pin, the flight crew to provide a salute, and the escort to salute in return. He did not mention the flashing of the taxi light. When asked about the step in the FOM that involved flashing the taxi light, he said that he normally flashed the taxi light, but he forgot to do so during the incident pushback. Thus, the captain’s description of the procedure was not identical to any of the descriptions in the GSM or FOM. Regardless of the differences between the captain’s description and other available descriptions of the final communication procedure, the captain’s understanding was that he was supposed to see the escort’s display of the pin and acknowledge by providing a salute. In an interview, the captain stated that he did so; however, a variety of other evidence suggests that he did not. The escort did not recall seeing a salute from the captain, which is why he remained in position. The control service agent did not see the captain look in her direction or provide a salute when she was outside the tow tractor cab and trying to attract his attention. The FO was preoccupied with his own tasks, but he did not recall seeing the captain provide a salute. The cockpit voice recorder (CVR) recording did not capture the collision itself or the events preceding the incident, but did capture the flight crew’s conversation following the incident. The captain’s comments after the incident revealed concern that he had not provided the salute or was uncertain if he had provided the salute. The captain’s subsequent interview statement that he had provided a salute could have resulted from a contamination of his memory (due to the passage of time), or from concerns about disclosing potential noncompliance with a required procedure. Available evidence indicates it is most likely that the captain did not see the escort display the pin or provide a salute. Interviews with the flight crew indicated that they completed numerous operational tasks during the pushback and before beginning the taxi. Although multitasking is common during pushback, in this incident, the flight crew was required to complete two additional simultaneous tasks – the manual engine start procedure and reviewing/entering the load closeout information – which increased their cognitive loading and the likelihood of error. Neither crew member appeared to recognize how the demand on mental resources imposed by these additional tasks could impact their monitoring and awareness of the pushback procedures being conducted outside the airplane. The FOM gave flight crews some discretion regarding the load closeout, stating that when possible, it should be reviewed before taxi. If the load closeout was not received before completion of the after-start checklist, taxi to the departure runway was allowed; however, the review was required to be completed before takeoff. Both the departure salute and the “clear left” callout before initiating the taxi could have alerted the flight crew to the captain’s omitted visual confirmation of the removal of the steering bypass pin and the continued presence of the tow tractor. However, the evidence suggests that these procedural safeguards were likely performed in a rote fashion and without focused attention, which resulted in the presence of the tow tractor in the airplane’s taxi path to go undetected. While it is understandable that the flight crew chose to perform tasks related to the load closeout during the pushback in an attempt to increase efficiency, it is likely that this incident may have been avoided had the flight crew delayed their load closeout related tasks until after the pushback procedure was complete. Tow Tractor Lighting FAA guidance classifies pushback tractors as aircraft support vehicles and requires those that operate in the airport movement area to be equipped with a yellow flashing light mounted on the uppermost part of the vehicle structure. The yellow flashing light must be visible from any direction, day and night, including from the air. In addition, U.S. Department of Transportation Regulations pertaining to the state of Hawaii specify that, “Any vehicle proceeding onto the movement area between the hours of sunset and sunrise except those being escorted shall also operate an overhead flashing light which is visible for one mile.” The yellow flashing light is required to increase the conspicuity of ground vehicles in the airport movement area and to aid in their detection by flight crews and other vehicle operators. The tow tractor involved in this accident had a yellow flashing light mounted on its cab, as required. The tow tractor operator said that the light activated automatically when the tractor was “in motion” and deactivated when the tractor was “turned off.” They believed the light was illuminated during operation of the tow tractor. However, airport surveillance video revealed that the light was not illuminated during incident pushback. Further investigation revealed that the yellow light would only illuminate if the tow tractor’s ignition was on and the light’s rocker switch (located on the dash) was also switched on. The position of the rocker switch was not documented following the incident, and its position at the time of the incident could not be determined. It is likely that the tow tractor was inadvertently operated without the yellow flashing light illuminated, and that the absence of the light contributed to the captain overlooking the presence of the tow tractor as he began the taxi. Communications “Off Headset” Airport surveillance video and ramp agent interviews indicated that the escort and the tow tractor did not reposition away from the airplane’s path after the escort removed the communication cable and nosewheel bypass pin. The tow tractor remained about 10 feet from the side of the airplane’s fuselage, facing the left wing. The escort remained next to the tow tractor. The flight crew did not flash the airplane’s taxi light, and the escort did not wait for this signal to display the pin. The escort also discontinued use of his illuminated wands earlier during the pushback process, although the wands were required to be used for all signaling during night or low-visibility operations. The absence of the illuminated wand made the escort’s pin display less salient to the flight crew, and made it harder to attract the flight crew’s attention. Finally, the escort did not provide a final salute to the flight crew; thus, final communication attempts by the ramp crew were not conducted in accordance with procedures in the GSM. The GSM stated that, once “off headset,” the flight crew could re-establish communications with the ramp crew by flashing the taxi light three times; however, no such procedure was outlined for the ramp crew to re-establish communication with the flight crew after disconnecting the headset. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

• — Environmental issues-Physical environment-Object/animal/substance-Ground equipment-Compliance w/ procedure
• — Personnel issues-Task performance-Use of equip/info-Use of policy/procedure-Ground crew
• — Personnel issues-Task performance-Use of equip/info-Use of checklist-Flight crew
• — Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Effect on operation
• — Personnel issues-Action/decision-Action-Forgotten action/omission-Pilot
• — Personnel issues-Action/decision-Action-Incomplete action-Ground crew
• — Environmental issues-Physical environment-Object/animal/substance-Ground equipment-Effect on operation