DCA24LA034

The captain did not verify that the tow tractor had exited the area in front of the airplane before taxiing for departure. Contributing factors were the dark conditions and the absence of an illuminated hazard beacon on the tow tractor, which reduced its conspicuity; the tow tractor operator’s positioning of the tractor too close to the airplane; the captain’s forgetting to verify the ramp agent’s display of the nosewheel bypass steering pin and provide him a return salute due to the performance of competing operational tasks; the flight crew’s rote performance of the “departure salute” checklist item and the required visual check of the sides of the airplane before commencing the taxi; and the ground crew’s discarding lighted wands during the pushback, which subsequently made it more difficult for them to attract the captain’s attention. In addition, the lack of procedure for ground crew to re-establish communications with the flight crew once the headset is disconnected from the airplane.

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

Captain 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. According 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. On 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 no