Individually Owned: 150,657
Corporate Owned: 137,281
San Diego International Airport
Aircraft Accident/Incident Report
San Diego, California 92112
Monday, June 27, 2005 18:18 PDT
NTSB Narrative Summary Released at Completion of Accident
The airplane surged forward and impacted a tug when the number 2 engine went to full power during engine start. According to the flight crew's written statements, the captain had written up the number 2 thrust reverser following the previous flight because it required extra effort and movement to reach normal reverse thrust. Maintenance personnel adjusted the rigging and released the aircraft for service. The flight crew informed maintenance that they would verify the rigging after engine start. The airplane was pushed back and the flight crew started the number 1 and 2 engines with no anomalies noted. They were in the process of starting the number 3 engine, when they heard a loud roar of an engine and felt the airplane lunge forward. The flight engineer announced the number 2 throttle was open and pulled the throttle lever to idle. The captain applied brake pressure and called for engine shutdown. According to the captain, he did not notice the number 2 throttle move forward because he was looking at the ground crew for a brake signal. The copilot did not observe the number 2 throttle move forward because he was concentrating on starting the number 3 engine and examining the oil pressure gauges for the number 1 and 2 engines. The flight engineer indicated that he had not noticed the number 2 throttle movement because he was looking at his panel to confirm that the number 2 start valve had closed and the number 3 start valve had opened. He then monitored the oil pressure when he heard the engine spooling up to high power followed by the movement of the airplane. A cockpit voice recorder was installed on the accident airplane, but review of the recording revealed that the engine start and accident had been recorded over. Mechanics examined the engine and throttle control rigging after the accident under the supervision of a Federal Aviation Administration airworthiness inspector. According to the mechanics and the airworthiness inspector, no anomalies were noted with the throttle's rigging. Subsequent engine runs were unsuccessful in duplicating the engine surge. The airplane was not equipped with an autothrottle system.
NTSB Probable Cause Narrative
the inadvertent throttle movement by one of the flight crew and the captain's inadequate supervision during the engine start sequence.
Event Information
| Type of Event | Accident |
| Event Date | 6/27/2005 |
| Event Day of the Week | Monday |
| Time of Event | 1818 |
| Event Time Zone | Pacific Daylight Time |
| Event City | San Diego |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 92112 |
| Event Date Year | 2005 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | Yes |
| Event Location Latitude | 324401N |
| Event Location Longitude | 1171123W |
| Event Location Airport | San Diego International |
| Event Location Nearest Airport ID | SAN |
| 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 | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1751 Pacific Daylight Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | SAN |
| Elevation of weather observation facility | 15 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | PDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | 2300 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 19 |
| Dew Point at event time (in degress fahrenheit) | 12 |
| Wind Direction (degrees magnetic) | 270 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 7 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.91 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 3 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 20976 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | May 27 2005 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Feb 26 2007 11:14AM |
| User who most recently changed record | NTSB\lema |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | San Diego, CA |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N357KP |
| NTSB Number | LAX05LA218 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | No |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Boeing |
| Aircraft Model | 727-230 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 20675 |
| Certified Max Gross Weight | 191000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 3 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Jun 1 2005 12:00AM |
| Airframe hours since last inspection | 0 |
| Airframe Hours | 65697 |
| ELT Installed | No |
| ELT Activated | -- |
| ELT Aided Location of Event Site | -- |
| ELT Type | -- |
| Aircraft Owner Name | 727 Aircraft One, Inc. |
| Aircraft Owner Street Address | 6200 Hazeltine National Drive |
| Aircraft Owner City | Orlando |
| Aircraft Owner State | FL |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 32822 |
| Operator is an individual? | No |
| Operator Name | Capital Cargo International |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 7100 TPC Drive, Suite 200 |
| Operator City | Orlando |
| Operator State | FL |
| Operator Country | USA |
| Operator Zip code | 32822 |
| Operator Code | C8GA |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Non-scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Cargo |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | SAN |
| Departure City | San Diego |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 1825 |
| Departure Time Zone | PDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | DEN |
| Destination City | Denver |
| Destination State | CO |
| Destination Country | USA |
| Specific Phase of Flight | Standing - engine(s) operating |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Nov 29 2006 5:46PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |