According to the NTSB, the accident occurred because "Bogucki made a "decision to use improper equipment" to push back an airplane from the gate."
The report states there were two pushback tugs and two tow bars to choose from and that Bogucki used a tow bar that was too short for the tug she was driving. A tow bar is a long, straight bar that connects the tug to the airplane’s front-wheel assembly.Why this "improper decision" was made, the report doesn't say. One thing is certain. Bogucki, 43 and the mother of two grown sons, was no novice. She had worked for Northwest for 13 years.
The accident occurred on the evening of Sept. 12, 2003, when Bogucki had connected one end of a tow bar to the airplane and was driving the tug slowly toward the other end, trying to attach it to the tug.
The NTSB report states that the tow bar buckled and the tug struck the nose of the plane. Bogucki, who was riding in the open-air cab of the moving tug, was pinned between the tug and the plane.
Unfortunately, the NTSB, unlike its sister agency, the US Chemical Safety and Hazard Investigation Board, does not always look for the "root causes" of such incidents. But by focusing more on the immediate cause, the agency fails to identify to underlying causes which, if addressed, can prevent similar accidents from happening in the future.
Again, I don't know what the NTSB was thinking, but we do know what the union, Virginia OSHA and Northwest Airlines were thinking.
The union contends she was using the only equipment Northwest provided to do the job. Union officials say Northwest had just one pushback tug, and that only one of the two tow bars would fit the DC-9 plane at the gate.Virginia OSHA probably didn't think much of the NTSB's conclusion either:
"She had no choice to make," said Bob Bennek , safety and health director of the International Association of Machinists and Aerospace Workers Air Transport District 143. He added that even if the other tow bar did fit the plane, it was shorter than the one Bogucki used....
"This is the worst publication I’ve ever seen the NTSB put out," Bennek said. "They’re misstating the facts… I don’t get it. It very much upsets me."
Bogucki was trying to do a job alone that many in the industry say takes two to do safely.
Before she died, Northwest workers had complained that staffing cutbacks were jeopardizing safety. Staffing was not mentioned in the federal report.
The Virginia Occupational Safety and Health Administration fined Northwest $6,300 for a "serious" violation of workplace safety laws. The maximum penalty for that violation was $7,000.Northwest Airlines, which is contesting the OSHA penalty, made no statement about the NTSB report. But actions speak louder than words:
State safety officials wrote that Northwest failed to provide a work environment that was “free from recognized hazards that were causing or likely to cause death or serious physical harm.” They also stated that employees “were exposed to crushing hazards while conducting aircraft pushback operations.”
Shortly after the accident, Northwest began requiring two people for pushbacks. The airline also replaced the open-air tug at Norfolk with a vehicle with an enclosed driver’s cab that offers more protection.Machinists leader Bennek said
he had hoped the NTSB findings would be strong enough to spur an industry-wide movement for eliminating open-air tugs and standardizing the length of tow bars.That would have been nice.
"We were hoping to have a detailed finding to help the whole industry prevent this from ever happening again," he said.