MCDONNELL DOUGLAS DC-9-83AMERICAN AIRLINES INC
Los Angeles Intl Airport, CA, USA · 2008-12-26·N9617R
What happened
NTSB summary, verbatimThe first officer indicated that he advanced the left engine throttle during the airplane's taxi in order to clear what he suspected was a stuck bleed air valve. Although he suspected that he had only moved the throttle "about an inch", FDR data revealed it had been advanced to and remained at an extremely high power setting for approximately 28 seconds. This action, which occurred without the knowledge of the captain or the tug operator and without application of the parking brakes, resulted in a substantial increase in thrust that overwhelmed the tug's resistance until the airplane impacted the tug.
Photographs
11the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe first officer's unannounced advancement of the left engine throttle, which led to a sustained application of high thrust that caused the airplane to impact the tug.
Occurrence sequence
1 stepsNTSB coding · CICTT taxonomy- 1 · Pushback/towingGround collisiondefining event
Findings
1 causal · 0 contributing- CAUSEPersonnel issues › Action/decision › Action — Copilot
Sequence of events
9 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- SRN 105390-105480groundp.1Both engines at ground idle (N1 about 28/24%), then a brief symmetric increase to about 37/36% N1 with thrust levers near zero; pressure altitude about 136-142 ft throughout
- SRN 105534-105562groundp.2First reverse-range application: left TLA to -26 degrees with left N1 rising to 83.8% (fuel flow 8,560 lb/hr, EGT to about 462 C) while the right stayed at about -8 degrees and 38% N1
- SRN 105574-105626groundp.2Second application: both levers to about -16 to -33 degrees with left N1 reaching 93% and right 68%; left fuel flow 11,536 lb/hr, left EGT about 521 C, left EPR 2.016
- SRN 105826-105874groundp.5Third application: left to about -32 degrees (N1 92.8%, EPR 2.012) and right to about -18 degrees (N1 67.8%)
- SRN 105888-105934groundp.6Fourth application: left to about -33 degrees (N1 93.5%, EPR 2.023) and right to about -15 degrees (N1 54.8%)
- SRN 106108-106200groundp.8Series of short left-engine-only reverse applications (TLA about -31 to -35 degrees, N1 peaking about 70-72%) lasting 4-6 seconds each
- SRN 106350-106360, 106436-106450, 106486-106496, 106510-106518groundp.10Further short applications, mostly left engine, with N1 peaking 51-66%
- SRN 106594-106612groundp.13Final two-engine application: left to about -34 degrees (N1 87.5%, EPR 2.02) and right to about -16 degrees (N1 58.5%)
- SRN 106714-106728shutdownp.14Both engines shut down: N1 falling below 10%, fuel flow 32 lb/hr
NTSB analysis
from the final reportThe first officer indicated that he advanced the left engine throttle during the airplane's taxi in order to clear what he suspected was a stuck bleed air valve. Although he suspected that he had only moved the throttle "about an inch", FDR data revealed it had been advanced to and remained at an extremely high power setting for approximately 28 seconds. This action, which occurred without the knowledge of the captain or the tug operator and without application of the parking brakes, resulted in a substantial increase in thrust that overwhelmed the tug's resistance until the airplane impacted the tug.