Los Angeles International Airport
Aircraft Accident/Incident Report

Los Angeles, California 90045
Sunday, September 12, 1999 8:52 PDT

NTSB Narrative Summary Released at Completion of Accident

The flight was being pushed back by a tug when it contacted a lavatory service truck, which had pulled up at the rear of the airplane to service the lavatories. The airline uses one person pushback operations at this station for B737's. Under the procedure, the ground handler will walk around the airplane just before the pushback to ensure that the airplane's path is clear. Once the flight crew gives the clearance, the pushback commences without the aid of wing walkers or other safety observers. The handler assigned to this flight did his walk around after the jetway bridge had been moved back. Once he was cleared by the flight crew he leaned over the tow bar for one last look and then mounted the tractor to start the push. He did not see the lavatory service truck at any time and the lavatory driver did not verbally communicate his presence or intentions. The flight crew turned on the rotating beacon just before the aircraft started to move. During the push the handler felt resistance and stopped just as the lavatory service driver ran to the front of the airplane shouting for him to stop. Three calls had been made for lavatory service on this airplane, the last one 10 minutes prior to departure. The lavatory service driver originally assigned to handle this flight was busy. Another lavatory service driver heard the service request on the radio and responded to the airplane, arriving about 7 minutes prior to departure. When he arrived, the rotating beacon was not on, which signified to him that the pushback was not imminent. He parked his service truck under the tail of the airplane and proceeded to service the aft lavatory just as the airplane began to move and it contacted his truck. The airline's ramp operations manual states, 'Before approaching aircraft to perform last-minute servicing, at or near departure time, always establish positive verbal communication with the pushback tractor driver.'

NTSB Probable Cause Narrative

The lavatory service driver's failure to follow established company procedures and directives. A factor in the accident was the airline's use of a one person pushback procedure.

Event Information

Type of Event Accident
Event Date 9/12/1999
Event Day of the Week Sunday
Time of Event 852
Event Time Zone Pacific Daylight Time
Event City LOS ANGELES
Event State CALIFORNIA
Event Country --
Zipcode of the event site 90045
Event Date Year 1999
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport LOS ANGELES INTERNATIONAL
Event Location Nearest Airport ID LAX
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 855 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID LAX
Elevation of weather observation facility 54
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 15
Air Temperature at event time (in degrees celsius) 20
Dew Point at event time (in degress fahrenheit) 14
Wind Direction (degrees magnetic) 250
Variable Wind Indicator Unknown
Wind Speed (knots) 8
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 86
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 1448
NTSB Notification Source --
NTSB Notification Date Sep 13 1999 12:00AM
NTSB Notification Time 1033
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 12 2000 11:55AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N388UA
NTSB Number LAX99LA302
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Boeing
Aircraft Model 737-322
Aircraft Series Identifier 737-322
Aircraft Serial Number 24663
Certified Max Gross Weight 131000
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 141
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Aug 16 1998 12:00AM
Airframe hours since last inspection 3264
Airframe Hours 28364
ELT Installed Yes
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name WILMINGTON TRUST CO
Aircraft Owner Street Address RODNEY SQUARE
Aircraft Owner City WILMINGTON
Aircraft Owner State DE
Aircraft Owner Country
Aircraft Owner Zipcode 19890
Operator is an individual? --
Operator Name UNITED AIRLINES, INC.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address P.O. BOX 66100
Operator City CHICAGO
Operator State IL
Operator Country
Operator Zip code 60666
Operator Code UALA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code LAX
Departure City
Departure State
Departure Country
Departure Time 0
Departure Time Zone
Destination Same as Local Flt --
Destination Airport Code OAK
Destination City OAKLAND
Destination State CA
Destination Country
Specific Phase of Flight Taxi
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:30AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --