Ground Spoiler Activation in Flight/Hard Landing, Valujet Airlines Flight 558, Douglas DC-9-32

184 Pages·1998·1.37 MB·English

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PB96-9104O7
NTSB/AAR-96/07
NATIONAL
TRANSPORTATION
SAFETY
BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
GROUND SPOILER ACTIVATION IN FLIGHT/HARD LANDING
VALUJET AIRLINES FLIGHT 558
DOUGLAS DC-9-32, N922VV
NASHVILLE, TENNESSEE
JANUARY 7, 1996
6781
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NTSB/AAR-96/07 PB96-9104O7
NATIONAL TRANSPORTATION
SAFETY BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
GROUND SPOILER ACTIVATION IN FLIGHT/HARD LANDING
VALUJET AIRLINES FLIGHT 558
DOUGLAS DC-9-32, N922W
NASHVILLE, TENNESSEE
JANUARY 7,1996
Adopted: December 11, 1996
Notation 6781
Abstract: This report explains the ground spoiler activation in flight and subsequent hard landing
of ValuJet Airlines flight 558, N922VV, a Douglas DC-9-32 at Nashville International Airport,
Nashville, Tennessee. The safety issues discussed in the report include the adequacy of ValuJet’s
operations and maintenance manuals, specifically winter operations nosegear shock strut servicing
procedures; the adequacy of ValuJet’s pilot training/crew resource management training programs;
flightcrew actions/decisionmaking; the role of communications (flightcrew/flight attendants/
operations/dispatch/air traffic control); ValuJet’s flightcrew pay schedule; Federal Aviation
Administration (FAA) oversight of ValuJet; and the adequacy of cockpit voice recorder (CVR)
duration and procedures. Safety recommendations concerning these issues were made to the FAA
and ValuJet Airlines.
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CONTENTS
ABBREVIATIONS....................................................................................................................................................vi
EXECUTIVE SUMMARY......................................................................................................................................viii
1. FACTUAL INFORMATION................................................................................................................................1
1.1 HISTORY OF FLIGHT......................................................................................................................................1
1.2 INJURIES TO PERSONS.................................................................................................................................10
1.3 DAMAGE TO AIRPLANE...............................................................................................................................10
1.4 OTHER DAMAGE.........................................................................................................................................10
1.5 PERSONNEL INFORMATION..........................................................................................................................10
1.5.1 The Captain.........................................................................................................................................10
1.5.2 The First Officer..................................................................................................................................11
1.5.3 Flight Attendants.................................................................................................................................12
1.5.4 FAA Principal Operations Inspector (POI) for ValuJet......................................................................12
1.5.5 FAA Principal Maintenance Inspector (PMI) for ValuJet...................................................................12
1.6 AIRCRAFT INFORMATION.............................................................................................................................13
1.6.1 Landing Gear System...........................................................................................................................13
1.6.2 Ground Spoiler System........................................................................................................................15
1.6.3 Pressurization System..........................................................................................................................16
1.7 METEOROLOGICAL INFORMATION...............................................................................................................17
1.8 AIDS TO NAVIGATION..................................................................................................................................17
1.9 COMMUNICATIONS......................................................................................................................................17
1.10 AIRPORT INFORMATION...............................................................................................................................18
1.11 FLIGHT RECORDERS....................................................................................................................................18
1.11.1 CVR......................................................................................................................................................19
1.11.2 FDR.....................................................................................................................................................19
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1.12 WRECKAGE AND IMPACT INFORMATION.....................................................................................................20
1.13 MEDICAL AND PATHOLOGICAL INFORMATION.............................................................................................20
1.14 FIRE............................................................................................................................................................20
1.15 SURVIVAL ASPECTS.....................................................................................................................................20
1.16 TESTS AND RESEARCH................................................................................................................................21
1.16.1 Landing Gear System Examination.....................................................................................................21
1.17 COMPANY/OPERATIONS INFORMATION.......................................................................................................21
1.17.1 ValuJet’s Cold Weather/Winter Nosegear Strut Servicing Procedures...............................................21
1.17.2 ValuJet’s Manuals..............................................................................................................................22
1.17.2.1 ValuJet’s QRH and AOM..........................................................................................................................23
1.17.2.2 ValuJet’s COM...........................................................................................................................................25
1.17.2.2.1 In-flight Irregularity Procedures...........................................................................................................26
1.17.3 ValuJet’s Training Program................................................................................................................26
1.17.3.1 CRM Training............................................................................................................................................28
1.17.4 ValuJet’s Crew Pay Schedule/Criteria................................................................................................28
1.18 ADDITIONAL INFORMATION.........................................................................................................................29
1.18.1FAA Oversight......................................................................................................................................29
1.18.2 Postaccident FAA/ValuJet Actions......................................................................................................30
2. ANALYSIS...........................................................................................................................................................35
2.1 GENERAL....................................................................................................................................................35
2.2 COLD WEATHER/WINTER FLIGHT OPERATIONS..........................................................................................35
2.3 FLIGHTCREW ACTIONS/DECISIONMAKING...................................................................................................36
2.4 VALUJET’S TRAINING PROGRAM.................................................................................................................38
2.4.1 Crew Resource Management Training................................................................................................39
2.5 VALUJET PAY SCHEDULE............................................................................................................................39
2.6 COMMUNICATIONS......................................................................................................................................40
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2.7 CVR ISSUES................................................................................................................................................41
2.8 VALUJET ACTIONS/FAA OVERSIGHT..........................................................................................................42
3. CONCLUSIONS..................................................................................................................................................43
3.1 FINDINGS.....................................................................................................................................................43
3.2 PROBABLE CAUSE.......................................................................................................................................44
4. RECOMMENDATIONS.....................................................................................................................................46
5. APPENDIXES......................................................................................................................................................49
APPENDIX A - INVESTIGATION AND HEARING...........................................................................................49
APPENDIX B - COCKPIT VOICE RECORDER TRANSCRIPT......................................................................50
APPENDIX C - VALUJET FLIGHT 558 DIGITAL FLIGHT DATA RECORDER DATA PLOT.................75
APPENDIX D - AIR TRAFFIC CONTROL TRANSCRIPT AND STATEMENTS..........................................76
APPENDIX E - EXCERPTS FROM VALUJET AND DOUGLAS DOCUMENTS/MANUALS..................119
APPENDIX F - FAA DOCUMENTS/CORRESPONDENCE............................................................................147
v
ABBREVIATIONS
agl: above ground level, 7
AIM: Aeronautical Information Manual, 8
AOL: all operator letter, 14
AOM: aircraft operating manual, 1
APU: auxiliary power unit, 1
ARFF: aircraft rescue and fire fighting, 8
ATC: air traffic control, 7
ATIS: automatic terminal information service, 6
ATP: airline transport pilot, 11
CAM: cockpit area microphone, 19
CDL: configuration deviations list, 13
CFR: Code of Federal Regulations, 1
COM: company operating manual, 4
CRM: crew resource management, 11
CVR: cockpit voice recorder, 18
EPR: engine pressure ratio, 20
FAA: Federal Aviation Administration, 2
FAR: Federal Aviation Regulation, 22
FCOM: flightcrew operating manual, 6
FDR: flight data recorder, 18
FSDO: flight standards district office, 13
FSI: Flight Safety International, 24
G: vertical acceleration force, 19
IFR: instrument flight rules, 1
ILS: instrument landing system, 6
vi
IOE: initial operating experience, 24
LOS: line operational simulation, 28
MEL: minimum equipment list, 13
msl: mean sea level, 4
P&W: Pratt & Whitney, 13
PA: public address, 10
PMI: principal maintenance inspector, 12
POI: principal operations inspector, 12
psi: pounds per square inch, 6
QRH: quick reference handbook, 2
SB: service bulletin, 14
SN: serial number, 13
VMC: visual meteorological conditions, 1
vii
EXECUTIVE SUMMARY
About 1620 central standard time, on January 7, 1996, a Douglas Aircraft
Company DC-9-32, N922VV, operated by ValuJet Airlines, Inc., as flight 558, touched down
hard in the approach light area short of runway 2R at the Nashville International Airport in
Nashville, Tennessee. Flight 558 was operating under the provisions of Title 14 Code of Federal
Regulations Part 121, as a scheduled, domestic passenger flight from Atlanta, Georgia, to
Nashville. The flight departed the William B. Hartsfield Atlanta International Airport at
approximately 1540, with five crewmembers and 88 passengers on board. The flight attendant
who occupied the rear cabin jumpseat and four passengers reported minor injuries; no injuries
were reported by the remaining 88 occupants. The airplane sustained substantial damage to the
tail section, nosegear, aft fuselage, flaps, slats, and both engines. Visual meteorological
conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
The National Transportation Safety Board determines that the probable cause of
this accident was the flightcrew’s improper procedures and actions (failing to contact system
operations/dispatch, failing to use all available aircraft and company manuals, and prematurely
resetting the ground control relay circuit breakers) in response to an in-flight abnormality, which
resulted in the inadvertent in-flight activation of the ground spoilers during the final approach to
landing and the airplane’s subsequent increased descent rate and excessively hard ground impact
in the runway approach light area.
Contributing factors in the accident were ValuJet’s failure to incorporate cold
weather nosegear servicing procedures in its operations and maintenance manuals, the
incomplete procedural guidance contained in the ValuJet quick reference handbook, and the
flightcrew’s inadequate knowledge and understanding of the aircraft systems.
The safety issues discussed in this report include the adequacy of ValuJet’s
operations and maintenance manuals, specifically winter operations nosegear shock strut
servicing procedures; the adequacy of ValuJet’s pilot training/crew resource management
training programs; flightcrew actions/decisionmaking; the role of communications
(flightcrew/flight attendants/operations/dispatch/air traffic control); ValuJet’s flightcrew pay
schedule; Federal Aviation Administration oversight of ValuJet; and the adequacy of cockpit
voice recorder duration and procedures.
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