National Transportation Safety Board - Aircraft Accident/Incident Database

475 Pages·2001·1.54 MB·English

National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CHI99LA055 12/17/1998 1840 EST RReeggiiss## NN4477AAEE Traverse City, MI Apt: Cherry Capital Airport TVC
Acft Mk/Mdl AEROSPATIALE ATR42-300 Acft SN 0047 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Issued
Eng Mk/Mdl P & W 120 Acft TT 24339 Injury Index: NONE Flt Conducted Under: FAR 121
Opr Name: AMERICAN EAGLE AIRLINES INC Opr dba: AMERICAN EAGLE Aircraft Fire: NONE
Summary
American Eagle, flight 4047, was substantially damaged when it veered off runway 28 and impacted runway lights during touchdown. Night instrument
meteorological conditions with a visibility of 1/2 sm in snow and freezing fog prevailed at the time of the accident. Flight 4047 was cleared for the ILS 28 approach
and began its descent at a point 1.6 nm inbound from the outer marker. While on the final approach segment, the airplane reached a descent rate of 2,000 fpm
and the alerts defining the outer and inner envelopes of the ground proximity warning system sounded. During the descent, the airplane's indicated airspeed
varied from 160 knots to 122.8 knots. The flight crew briefed an icing approach speed of 123 knots with the first officer acting as the flying pilot. Fifty-six seconds
prior to touchdown, air traffic control (ATC) issued winds 070 degrees at 17 knots with a runway 28 Mu of 82,85,81 and chemically treated thin loose snow over
patchy ice. The tailwind component was 14.722 knots. The first officer transferred the flight controls to the captain at approximately 400-500 feet agl. Two
seconds prior to touchdown, ATC issued winds 060 degrees at 20 knots. The tailwind component was 15.320 knots. The southern runway lights extending from
2,574 feet - 3,311 feet down the runway were damaged. Flight data recorder information indicated that flight 4047 touched down in a 7 degree left bank attitude.
American Eagle had in place 'stabilized approach criteria' to define conditions which required a mandatory missed approach. The American Eagle Aircraft
Operating Manual stated that the limiting tailwind component for the airplane was 10 knots. Following the accident, an AE crew chief stated that the #1 MLG tire
was peeled off the rim and 'ripped up bad.' He described the #2 MLG tire as having side ways scuff marks on the treaded portion of the tire. He stated that he
performed an A/S test and if it was bad that he would have entered it into the minimum equipment list. The aircraft received a ferry permit, after the accident, to
be flown to Marquette for repair. The ferry captain reported that he flew the aircraft from TVC to Marquette. Prior to leaving the gate, he tested the antiskid (A/S)
system and one of the fault lights came on momentarily in which the captain described the duration as 'just a blink'. The Captain then executed a high speed taxi,
braked and then stopped the aircraft. He then tested the A/S light, and no light illuminated. He also reported that there were no problems en route or upon landing
at Marquette. He added that there was no fault light illumination during or after landing at Marquette.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The crew's failure to execute a
missed approach and the flying pilot's (captain) failure to maintain directional control upon touchdown with a seven degree left bank and a right quartering
tailwind. Factor's were the snow covered runway/landing area and the night conditions.
Sequence of Events
Type of Occurrence - Phase of Flight
Cause/Factor - Text
LOSS OF CONTROL - ON GROUND/WATER - LANDING - ROLL
CAUSE DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND
CAUSE MISSED APPROACH - NOT PERFORMED - FLIGHT CREW
FACTOR WEATHER CONDITION - UNFAVORABLE WIND - NOT REPORTED
FACTOR AIRPORT FACILITIES, RUNWAY/LANDING AREA CONDITION - SNOW COVERED - NOT REPORTED
FACTOR LIGHT CONDITION - NIGHT - NOT REPORTED
----- ATC CLEARANCE - DELAYED - ATC PERSONNEL(LCL/GND/CLNC)
ON GROUND/WATER COLLISION WITH OBJECT - LANDING - ROLL
----- OBJECT - RUNWAY LIGHT - NOT REPORTED
----- LANDING GEAR, TIRE - FRAYED - NOT REPORTED
Narrative
HISTORY OF FLIGHT
On December 17, 1998, at 1840 eastern standard time, an Aerospatiale ATR42-300, N47AE, operated by American Eagle Airlines, Incorporated, as flight 4047,
received substantial damage during landing on runway 28 (6,501 feet by 150 feet, asphalt/snow) at Cherry Capital Airport (TVC), Traverse City, Michigan. Night
instrument meteorological conditions prevailed at the time of the accident. The 14 CFR Part 121 passenger carrying flight was operating on an instrument flight
rules (IFR) flight plan. The 3 flight crew members and 40 passengers reported no injuries. The flight originated at Chicago O' Hare International Airport, Chicago,
Illinois, at 1730, and was en route to its scheduled destination of TVC. Austin Straubel International Airport (GRB), Greenbay, Wisconsin was filed as an alternate
airport.
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During the flight, the captain was acting as the non flying pilot (NFP) and the first officer was the flying pilot.
At 1813:40, radar data indicates that the aircraft is approximately 65 nmi southwest of TVC at 15,000 feet msl. At 1813:40, the cockpit voice recorder indicates
that the captain said, "information Lima, two two five six zulu. winds are three two zero at ten. two and a half, light snow, mist. ... one thousand scattered, three
thousand broken, fifty five hundred broken, minus two, minus four, two niner niner four is already set left center. they're using the ILS to two eight. thin patchy, ice.
sanding and chemicals are in progress. ... landing's gonna be, thirty five thousand pound landing with icing speeds... call it one twenty three, one twenty three
squared.
In the Federal Aviation Administration's (FAA's) Air Traffic Control report of the aircraft accident, Minneapolis Air Route Traffic Control Center (ARTCC) told flight
4047 they were number two following a Cessna 152. Flight 4047 was then issued instructions to fly heading 300 to join the localizer with discretion to descend to
2,700 feet msl. Approximately three minutes later, ARTCC instructed flight 4047 to join the localizer for runway 28 and proceed inbound and to expect approach
clearance after the Cessna 152 was on the ground. At 1837:53, the CAPT said, "...there's GWENN right there...". At 1838:28 Minneapolis Center cleared Flight
4047 for the ILS 28 approach at TVC and was instructed to maintain two thousand seven hundred feet until on a published portion of the approach.
Radar data indicates that the aircraft maintained an altitude of 2,700 feet msl until it was 1.6 nmi inbound from the outer marker, on the ILS 28 approach. Thirty
six seconds later, the aircraft was at 1,500 feet msl and 3.3 nmi inbound from the outer marker.
At 1839:00 the cockpit audio mike recorded, "sink rate, sink rate, sink rate" followed by, "whoop whoop, pull up, whoop whoop, pull up, whoop whoop, pull up" at
1839:04. Five seconds later, the first officer called for 30 degrees of flaps.
At 1839:30 the TVC tower controller transmitted, "Eagle flight forty seven Tranverse City runway two eight. cleared to land. wind zero seven zero at one seven.
altimeter's two niner niner five. ... runway two eight Mu is eight two eight five eight one, with chemically treated thin loose snow over patchy ice." (See Test and
Research section for tailwind and crosswind components)
At 1839:44 a transmission from the accident aircraft responded, "cleared to land, Eagle forty seven."
At 1840:24 the TCV tower controller transmitted, "wind zero six zero at two zero." (See Test and Research section for tailwind and crosswind components)
At 1840:26 the cockpit audio mike recorded a "sound similar to aircraft touching down on runway".
In a debrief taken by American Eagle, Incorporated, on December 18, 1998, the captain reported:
"On approach to Traverse City we received a notice of weather change. This was approximately at the outer marker and made by the tower. The tower advised
us of the change in direction and velocity of the wind. At approximately three to five hundred feet the first officer positively transferred control of the aircraft to me.
I confirmed positive transfer of controls. The approach was stable. At touchdown the aircraft veered to the left. I returned the aircraft to the centerline and then
continued to the gate. The passengers deplaned by jetbridge. Upon postflight inspection damage to the aircraft was noted. I then contacted the company."
In a debrief taken by American Eagle Airlines, Incorporated, on December 18, 1998, the first officer reported:
"I was flying an ILS 28 to TVC. At approximately the outer marker there was a reported wind change. I flew the approach normally. At approximately 400-500 feet
agl, control of the aircraft was transferred to the captain. We continued visually upon touchdown the aircraft veered left. The captain brought the aircraft back to
the centerline and a normal taxi to the gate was accomplished. Upon postflight of aircraft, aircraft damage was discovered. To my knowledge the captain
contacted the company."
During a postaccident interview, the captain stated that he was inbound from Ft. Wayne on another flight, swapped aircraft in Chicago, obtained weather and
greeted the first officer at the gate. He reported that he reviewed the weather packet and maintenance logs, which did not have any open write ups. He described
the takeoff, flight and approach as normal into Traverse City, Michigan. He obtained information Lima and was vectored and subsequently cleared for the ILS 28
approach. He stated that the winds were reported as 030 at 17 knots, the crosswind component chart was pulled out on approach. He stated he was visual at 800
feet, and at approximately 500 feet, the first officer indicated to him that he [first officer] wanted to transfer control. He also stated that there was a positive
transfer of control. He stated that shortly after touchdown, the aircraft veered to the left and that he could not see the centerline. He stated that there were
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"windrows" of snow 10-15 feet from the edge of the runway. The captain added that he believed that he applied toe brakes shortly after touchdown and applied
some reverse. He also added that he could not remember if the aircraft began to veer before or after braking. He added that shortly after all three gear on the
aircraft touched down, the aircraft veered to the left. The captain stated that he had applied aileron control into the wind with slightly forward pressure. He
reported that he did not notice an anti skid fault.
During a postaccident interview, the first officer stated that it felt like a normal touchdown but that the nose went left. There was a "windrow" of snow 10 feet from
the edge of the runway. He stated that the captain hit the windrow and taxied back out. The first officer stated that he was not touching any of the flight controls
during the landing. He stated that the approach speed was 125-130 knots and bugged for icing speeds. He stated that the captain had given the ATIS
information. The first officer stated that prior to the outer marker the winds were reported as 030 at 17 knots and visibility went to 1/2 mile. He stated that they
discussed that it would be a crosswind and calculated the crosswind component with the tailwind component. The first officer stated that he transferred control
since he did not feel comfortable landing the aircraft after seeing the snow covered runway.
OTHER DAMAGE
The TVC Airport Operations Manager reported that runway lights 12, 13, 14, 15, and 16, located on the south side of runway 28, were "knocked down". The
"knocked down" lights were between taxiway H and the approach end of runway 23. The location of light 12 was reported to be 2,574 feet from the threshold of
runway 28. The distances between lights 12, 13, 14, 15, and 16 were reported to be 184 feet, 185 feet, 184 feet and 184 feet respectively.
PERSONNEL INFORMATION
The captain, age 41, was hired by American Eagle, Incorporated on June 25, 1990. He held an airline transport pilot certificate with an airplane multiengine rating,
and type ratings in the ATR42 and ATR72. He was upgraded to captain on March 27, 1998, and received a recurrent training check on September 26, 1998. The
captain had accumulated 8,000 total flying hours, 365 hours of which were as pilot-in-command in the ATR42. He had accumulated 90 hours in the ATR42 in the
preceding 90 days of the accident. The captain was issued a first class medical certificate on October 20, 1998. Duty time records showed that he was off duty on
December 15, 1998. On December 16, 1998, the captain reported, at 0830 CST, for a flight in the ATR72. The captain completed his duty period at 1020. On
December 17, 1998 the captain reported for duty at 1500 CST and had flown two flights in the ATR72 prior to the accident flight.
The first officer, age 41, was hired by American Eagle, Incorporated on July 20, 1998. He held a commercial pilot certificate with airplane single-engine land and
multiengine ratings. He was line qualified on September 17, 1998. The first officer had accumulated 3,520 total flying hours, 130 hours of which were in the
ATR42. He had accumulated 100 hours in the ATR42 in the preceding 90 days of the accident. The first officer was issued a first class medical certificate on
September 9, 1998. Duty time records showed that he was off duty for a 48-hour period preceding the day of the accident. On December 17, 1998, the first officer
reported for duty 1054 CST and had flown two flights in the ATR42 prior to the accident flight.
AIRCRAFT INFORMATION
N47AE, an ATR42-300, serial number 0047, was manufactured by Aerospatiale in 1987 and had accumulated a total airframe time of 24,339 hours and 30,354
cycles. The aircraft was maintained on an approved inspection program and had last been inspected on October 16, 1998, at an airframe time of 23,993 hours
and 29,904 cycles. The aircraft was fitted with two Pratt and Whitney 120 turboprop engines rated at 2,000 shaft horsepower each. The aircraft accommodates a
crew of 4 with 46 passengers and has a maximum landing weight of 36,160 lbs.
The load manifest from Flight 4047 indicated an actual aircraft landing weight of 34,958 lbs. The ATR42-300 operating speeds for icing conditions is listed in AE's
ATR42/72 Aircraft Operating Manual (AOM). For "conservative maneuvering" at 15 degrees of flaps, the airspeed is 145 knots for all weights. Vapp is defined as
the minimum approach speed in a landing configuration prior to threshold and is equal to VmHB Flap + Wind. At an aircraft landing weight of 35,000 lbs, VmHB
15 is 115 knots and VmHB 30 is 120 knots.
The ATR42 Flight Crew Operating Manual describes the Ground Proximity Warning System (GPWS) alert modes by stating that, "When the aircraft penetrates
the outer envelope, the "SINK RATE" voice alert is given and the red GPWS warning lts [lights] illuminate. If the inner envelope is penetrated, the "WHOOP
WHOOP PULL UP" alert is given. This mode does not depend on the aircraft configuration." A graph of descent rate versus radio altitude (RA) depicts the "SINK
RATE" envelope as being bounded by the following coordinates: 1,000 fpm at 50 feet, 5,000 fpm at 2,450 feet, 7,000 fpm at 2,450 feet, 7,000 fpm at 2,300 feet,
1,500 fpm at 200 feet and 1,500 fpm at 50 feet. The "PULL UP" envelope is bounded by the following coordinates: 1,500 fpm at 50 feet, 1,500 fpm at 200 feet,
7,000 fpm at 2,350 feet and 7,000 fpm at 50 feet.
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The ATR42 Aircraft Flight Manual indicates that the tail wind limit of the ATR42 was 15 knots and also states:
"The capability of the airplane has been satisfactorily demonstrated for take off and manual landing with tailwinds up to 15 knots. This finding does not constitute
operational approval to conduct take off and landing with tail wind components in excess of 10 knots."
The American Eagle ATR 42/72 AOM states, under "Operation Limits", the limiting tailwind component to be 10 knots.
METEOROLOGICAL INFORMATION
The dispatch release for flight 4047 indicates that the TVC Field Report issued on December 17, 1998 at 1706 stated that runway 28 conditions were wet in .00
water with a braking action/remarks of 100, 95, 99. A special advisory within in the field report states, "use caution-10/28 wet, men and eqp [equipment] on field
plowinf [plowing] in progress". It also reported the TVC terminal area forecast, issued at 1318 to be, wind 330 degrees at 13 knots; 4 smi visibility in light snow
showers; overcast clouds at 2,500 feet; temporary conditions of wind 180 degrees at 2 knots; visibility of 1 smi in snow showers; overcast clouds at 800 feet agl.
At 1840:26, the TVC automated surface observing system (ASOS) special observation recorded wind from 050 true degrees at 16 knots; prevailing visibility of 1/2
smi in snow and freezing fog; few clouds at 1,000 feet agl, broken clouds at 2,400 feet agl and overcast clouds at 5,000 feet agl; temperature and dewpoint of -3
degrees Celsius (C); altimeter setting of 29.95 inches of Mercury (Hg); remarks of visibility 1/4 variable 1 smi. At 1853:26, the TVC ASOS recorded wind from 060
true degrees at 14 knots gusting 20 knots; prevailing visibility of 1/4 smi in heavy snow and freezing fog; overcast clouds at 100 feet agl; temperature and
dewpoint of -3 degree C and -4 degrees C; altimeter of 29.96 inches of Hg; remarks of tower visibility 1/2 smi; snow increasing, 1/4 smi visibility.
At 1856 CST (1956 EST), the GRB ASOS recorded, wind from 300 true degrees at 3 knots; prevailing visibility of 10 smi; clear sky conditions; temperature and
dewpoint of -5 degrees C and -11 degrees C; an altimeter setting of 30.01 inches of Hg. Night visual meteorological conditions with a wind of 7 knots or less
prevailed for the remainder of the day.
At 1856, the Kent County International Airport (GRR) ASOS, Grand Rapids, Michigan, reported, wind 300 true degrees at 7 knots; prevailing visibility of 10 smi;
clear sky conditions; temperature and dewpoint of -2 degrees C and -9 degrees C; altimeter setting of 29.99 inches of Hg. Night visual meteorological conditions
with a wind of 6 knots or less prevailed for the remainder of the day.
The magnetic variation at TVC was 5 degrees west.
Advisory Circular 00-45D, Aviation Weather Services, states that the ASOS wind is a 2-minute average wind computed once every 5 seconds.
AIDS TO NAVIGATION
TVC is served by one precision and three nonprecision approaches. The ILS runway 28 approach possesses straight-in minimums of 200 feet and 1/2 mile
visibility and circling minimums of 800 feet and 2-1/4 miles visibility for all categories. The minimum altitude at the intermediate segment of the ILS 28 approach
was 3,000 feet msl. The outer marker, GWENN, is located 5.8 nmi from runway 28 and has a glidepath altitude of 2,549 feet msl. The ILS 28 approach chart
indicates that the glideslope for the approach is 3 degrees.
AIRPORT INFORMATION
TVC airport elevation is 624 feet msl. Runway 28 lighting includes high intensity runway lights (HIRL) and a medium intensity approach lighting system (MASLR)
with runway indicator lights.
At 1828, TVC reported that the runway center was 80 feet wide and chemically treated. The remainder of the runway had loose snow over patchy thin ice.
Runway friction was reported as 82, 85 and 81.
GRB and GRR are both AE stations located 110 nmi west and 112 nmi south of TVC respectively.
TESTS AND RESEARCH
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In a written statement, a pilot stated that he had written up N47AE's #2 main landing gear (MLG) tire on December 16, 1998. He stated, "I noticed no
abnormalities during any portion of the ORD-EVV [Evansville Regional Airport, Evansville, Indiana] flight until the landing at EVV. I was the NFP, with the FO
making the landing. The landing was made on runway 22, which was damp/dry, and as I recall, the winds were fairly light. The landing, made by the FO, was a
normal landing with little if any braking applied by him. As I took control of the A/C, started to apply braking, and continued to apply reverse, we smelled an odor
like hot rubber. Braking seemed to be a little sluggish, but I noted no anti-skid faults, or any other abnormal indication, other that the smell. I commented that we
might have a tire problem. At the gate, during the postflight inspection, we discovered the #2 MLG tire was flat with a large flat area worn completely through the
cord layers." On December 16, 1998, the pilot entered into the mechanical discrepancy log, "On post flight inspection, found #2 MLG tire flat with large hole
completely through cord". The corrective action indicated that the #1 and #2 MLG tire assemblies were ran and inspected and the operational check was
described as good.
On December 17, 1998, there were three flights accepted by two different captains and no mechanical discrepancies, relating to MLG, were entered into the
aircraft maintenance log prior to the accident flight.
Following the accident, the TVC station manager submitted a diagram of one of the tires from the accident aircraft which had a flat spot on it approximately 8-10
inches in length with a build up of melted rubber spanning the width of the tire.
Following the accident, an AE crew chief stated that the #1 MLG tire was peeled off the rim and "ripped up bad." He described the #2 MLG tire as having side
ways scuff marks on the treaded portion of the tire. He stated that he performed an A/S test and if it was bad that he would have entered it into the minimum
equipment list.
The aircraft received a ferry permit, after the accident, to be flown to Marquette for repair. The ferry captain reported that he flew the aircraft from TVC to
Marquette. Prior to leaving the gate, he tested the A/S system and one of the fault lights came on momentarily in which the captain described the duration as "just
a blink". The Captain then executed a high speed taxi, braked and then stopped the aircraft. He then tested the A/S light, and no light illuminated. He also
reported that there were no problems en route or upon landing at Marquette. He added that there was no fault light illumination during or after landing at
Marquette. The captain stated that he saw tires in the cargo hold and that one of the tires felt as if it was melted on an 8 - 10 inch area in length and spanning the
full length of the tire. He stated that he did not know which tire it was. He also reported that he did not see any skid or burn marks on the other tires.
On January 16, 1999, a mechanical discrepancy was entered as, "severe nose wheel vibration above 50 KIAS both t/o and landing - directional control not a
problem". The corrective action taken states that the #1 tire was found to have torn plies.
The American Eagle Flight Manual states, under Stabilized Approach Criteria, "when any approach fails to meet the following stabilized approach criteria, an
immediate missed approach (or go around as appropriate) is mandatory. Aircraft specific procedures outlined in the Aircraft Operating Manual Vol. 1 [AOM]
supersede this section." It goes on to say that, "the stabilized approach criteria is divided into three phases of flight, and applies to both instrument and visual
approaches..."
The AOM states that for ILS approaches, prior to beginning the final approach segment, the desired altitude is maintained +/-100 feet, the desired airspeed within
+/- 10...
Phase 1 1) 2,000 Feet AFL to 1,000 Feet AFL [above field elevation] 2) Maximum Descent Rate: 2,000 FPM [feet per minute] 3) Maximum Course Deflection
Once Established: +-1.5 dots or +- 7 degrees on RMI [Radio Magnetic Indicator]
Phase 2 1) 1,000 Feet AFL to 300 Feet AFL 2) Maximum Descent Rate: 1,200 FPM 3) Maximum Course Deflection: +-1 dot or +-5 degrees on RMI 4) Minimum
Speed briefed approach speed as appropriate.
Phase 3 1) 300 Feet to 59 Feet AFL 2) Maximum Descent Rate: 900 FPM 3) Maximum Course Deflection: (ILS/LOC only) +-1 dot 4) Maximum Speed Deviation:
Deceleration, as required, to cross end of runway at a speed difference not in excess of +10/-0 knots of appropriate threshold speed.
ATR reported that with a wind from 070 degrees at 17 knots, relative to a runway heading of 280 degrees, the tailwind component would be 14.722 knots with a
crosswind component of 8.5 knots. With a wind from 060 degrees at 20 knots, relative to a runway heading of 280 degrees, the tailwind component would be
15.320 knots with a crosswind component of 12.855 knots.
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A readout of the Digital Flight Recorder (DFDR) was performed by the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory. Data from the
aircraft's DFDR shows that at a RA of 945 feet, the aircraft's indicated airspeed was 160 knots. At a RA of 100 feet the aircraft's indicated airspeed was 122.8
knots. The NTSB's factual report of the DFDR readout defines a subframe reference number (SNR) as being equivalent to one second. The factual report of the
readout includes the following statement:
"... At 2343, the aircraft is on runway heading of 279 degrees, at a radio altitude of 27 feet, -5 degrees left bank, 5 degrees left aileron, a pitch of 0 degrees, above
the glidesplope and on the localizer. At SRN 2347, the radio altitude is at 3 feet, the airspeed is 103 knots, a magnetic heading of 277 degrees, a roll of -7
degrees left, the rudder moves from -5 degrees to 4 degrees, and the glidesplope is full-scale above. At SRN 2348, there is a vertical acceleration spike of 1.4
g's, and lateral acceleration starts to increase as longitudinal acceleration starts to decrease and the localizer indicates left of the beam. Over the next 4 seconds,
the roll decreases from -6 degrees left to zero, the aileron increases, the magnetic heading changes from 279 degrees to 284 degrees, and the rudder fluctuates.
During SRN 2352, the roll increases to the right, positive lateral acceleration reaches a maximum value of .232 g's and the heading is 290 degrees. ..."
ADDITIONAL INFORMATION
The Airline Pilot's Association (ALPA) submitted 19 pages of comments regarding the accident. ATR submitted 2 pages of comments regarding the accident.
Both comments by ALPA and ATR are attached to this report.
The FAA, American Eagle, Incorporated, ALPA and ATR were parties to the investigation.
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Incident Rpt# NYC99IA062 02/16/1999 1602 EST RReeggiiss## NN662288AAWW Columbus, OH Apt: Port Columbus Intl Arpt CMH
Acft Mk/Mdl AIRBUS A-320-231 Acft SN 67 Acft Dmg: MINOR Rpt Status: Factual Prob Caus: Issued
Eng Mk/Mdl IAE V2500-A1 Acft TT 28404 Injury Index: NONE Flt Conducted Under: FAR 121
Opr Name: AMERICA WEST AIRLINES Aircraft Fire: NONE
Summary
When the landing gear was lowered, the flight crew received landing gear control and interface unit (LGCIU) faults. A visual fly-by revealed the nose wheels were
rotated 90 degrees from the desired direction for landing. A normal touchdown was made, after which, the captain commanded an emergency evacuation using
the overwing exits. Examination of the airplane revealed the external 'O' rings in the steering control valve had extruded and by-passed pressurized hydraulic fluid
to rotate the nose wheels. This event had occurred before, and the manufacturer had issued a service bulletin. The operator had not complied with the service
bulletin, nor were they required to comply with it.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: a failure of the external o-rings in
the nose landing gear steering module.
Sequence of Events
Type of Occurrence - Phase of Flight
Cause/Factor - Text
AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTION - APPROACH - IAF TO FAF/OUTER MARKER (IFR)
CAUSE LANDING GEAR, STEERING SYSTEM - FAILURE - NOT REPORTED
----- MAINTENANCE, SERVICE BULLETIN/LETTER - NOT COMPLIED WITH - COMPANY MAINTENANCE PERSONNEL
Narrative
On February 16, 1999, at 1602 Eastern Standard Time, an Airbus A-320-231, N628AW, operated by America West Airlines as flight 2811, received minor
damage when it landed at Port Columbus International Airport (CMH), Columbus, Ohio, with the nose wheels rotated 90 degrees. There were no injuries to the 2
certificated pilots, 3 flight attendants and 26 passengers. Visual meteorological conditions prevailed for the scheduled passenger flight which had departed from
Newark (EWR), New Jersey, about 1404. Flight 2811 was operated on an instrument flight rules flight plan conducted under 14 CFR Part 121.
According to statements from the flight crew, flight 2811 was uneventful until the landing gear was lowered prior to landing at CMH. After the landing gear was
extended to the down-and-locked position, the flight crew received indications of dual landing gear control and interface unit (LGCIU) faults.
The flight crew entered into a holding pattern and attempted to troubleshoot the faults; however, they were unable to determine the source of the problem. The
flight crew then prepared for a landing at CMH, with nosewheel steering and thrust reversers inoperative due to the faults. During the final approach, at the flight
crew's request, the control tower performed a visual check of the landing gear, which revealed that the nosewheels were rotated about 90 degrees.
The flight crew then initiated a missed approach and declared an emergency. The cabin crew was notified of an impending emergency landing, and the cabin and
passengers were prepared for the landing. The captain initiated the approach, and described the touchdown as soft. The airplane stopped on the 10,250-foot-long
runway with about 2,500 feet of runway remaining. Damage was limited to the nose landing gear tires and rims.
The captain reported that after landing, he noticed smoke was drifting up on the right side of the airplane. He said he attempted to contact the control tower and
confirm if a fire was present, but was unable due to frequency congestion. He then initiated an emergency evacuation using the left and right side overwing exits.
A review of the air/ground communications, as recorded by the Columbus Air Traffic Control Tower, did not reveal a congested frequency when the emergency
evacuation was initiated.
According to Airbus, nose wheel steering was hydraulically actuated through either the cockpit tiller and/or the rudder pedals.
A post-incident visual inspection of the nose landing gear assembly revealed no anomalies. The steering control module was replaced, and a subsequent
functional check of the nosewheel steering was successful.
The steering control module was a sealed unit, opened only during overhaul, with no specified overhaul time, and had accumulated 3,860 hours since last
overhauled on March 3, 1998. It was shipped to Messier-Bugatti, the manufacturer, and examined under the supervision of the French Bureau Enquetes
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accidents (BEA). The examination revealed that the external hydraulic O-ring seals on the steering control module's selector valve were extruded (distorted out of
the seal's groove). A small offset was found in the steering control valve.
Airbus further reported that while the offset would have been measurable, it would not have been noticeable under normal operations. Additionally, during landing
gear extension, the brake and steering control unit (BSCU) would have been energized and hydraulic pressure would have been directed toward the steering
servo valve. The BSCU would have then commanded a small rotation of the nose wheel to check for proper movement. Any disagreement between the
commanded position and actual position of the nose wheel would have deactivated the nose wheel steering. However, if hydraulic pressure had bypassed the
steering control valve, there would have been continued pressurization to the servo valve, and because of the servo valve's inherent offset, in-flight rotation of the
nose wheels.
Procedures existed for removal of hydraulic pressure from the steering control module. However, once the nosewheel strut had deflected 90 degrees, the
centering cam would have been rotated to a flat area, and would have been incapable of overriding the 3,000 PSI hydraulic system, and returning the nose
wheels to a centered position.
Documents from Airbus indicated there have been three similar incidents in which A320 airplanes landed with the nose wheels rotated about 90 degrees.
Examination of the steering control modules on two of the airplanes revealed extrusion of the selector valve's external seals similar to that found on N628AW.
Airbus had attributed the extrusion failures to the lack of a backup seal or the effects of aging on the seals. As a result of these incidents, Airbus issued Service
Bulletin (SB) A320-32-1197 on October 8, 1998, to recommend replacement of the external seals on the steering control module's selector valve on A320 and
A321 airplanes within 18 months of the SB's issuance.
At the time of the incident, neither the French Direction General de l'Aviation Civile (DGAC), or the Federal Aviation Administration (FAA), had adopted the
service bulletin as an airworthiness directive. The operator was not required to comply with the service bulletin, and had not complied with it.
On March 24, 1999, the DGAC issued Airworthiness Directive (AD) 1999-124-129(B) to require compliance with the SB. On December 17, 1999, the FAA issued
AD 99-23-09 which was based upon the French AD, with a 12 month time of compliance for modification of the nose wheel steering control valve.
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National Transportation Safety Board - Aircraft Accident/Incident Database
Incident Rpt# LAX01SA162 04/19/2001 1815 PDT RReeggiiss## NN331199UUSS San Francisco, CA
Acft Mk/Mdl AIRBUS INDUSTRIE A-320-211 Acft Dmg: MINOR Rpt Status: Prelim Prob Caus: Pending
Flt Conducted Under: FAR 121
Opr Name: Northwest Airlines, Inc. Aircraft Fire:
Narrative
On April 19, 2001, at 1815 hours Pacific daylight time, an Airbus Industrie A320-211, N319US, received minor damage when the aft, lower fuselage belly skin
contacted the runway during landing at San Francisco International Airport, San Francisco, California. The airline transport certificated pilot, the other 4
crewmembers, and 126 passengers were not injured. The aircraft was operated by Northwest Airlines, Inc., under 14 CFR Part 121 as flight 51, a regularly
scheduled, domestic, passenger flight. The flight was operating on an instrument flight plan and visual meteorological conditions prevailed at the landing airport.
The flight originated at Detroit, Michigan, at 1526 eastern daylight time as a nonstop flight to San Francisco.
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# MIA00LA115 03/18/2000 1910 EST RReeggiiss## NN119999GGAA Miami, FL Apt: Miami International MIA
Acft Mk/Mdl BEECH 1900 Acft SN UB-13 Acft Dmg: MINOR Rpt Status: Factual Prob Caus: Issued
Eng Mk/Mdl P & W PT6A-65B Acft TT 29864 Injury Index: SERIOUS Flt Conducted Under: FAR 121
Opr Name: GULFSTREAM INT'L AIRLINES Aircraft Fire: NONE
Summary
The crew stated they were receiving marshalling instructions while taxiing the aircraft to parking during heavy rain. They said the ramp area was dark and the
aircraft's taxi, navigation and tail floodlights were illuminated, and the windshield wipers were operating. The captain said that during taxi, the yellow guideline into
the ramp area was very difficult to see, but he was taxiing the aircraft within 10 feet of the line. Both crewmembers said they never saw the tug until after the
collision, and when the aircraft door was opened, they realized that the baggage vehicle had collided with their aircraft. The police report showed that the pilot had
said in his initial report, that he felt as if the left wing had been pushed hard and he had observed that the aircraft's left propeller and wing, as well as the rear
baggage carts were damaged. The police report also showed that the baggage cart had been equipped with no lights, only reflectors, and that the distance from
the center of the yellow taxi line to the impact point where the debris lay was about 30 feet. In addition, a ramp control incident report showed that in addition to
the debris being located 30 feet from the yellow line, the debris was also located 73 feet from the aircraft containment line. The tug driver stated that he had been
driving as close to the fuchsia (red) line as was possible, when the collision occurred. The ramp supervisor who was marshalling the aircraft and witnessed the
collision stated that he was 100 feet away, and observed that the tug and cart was coming from the left side of the aircraft, trying to cross the taxiway from one
side to the other, and the tug driver did not notice the aircraft taxiing in, and tried to avoid hitting the aircraft by making a turn to the left, but he hit the airplane with
the cart, causing damage to the airplane's left wing and propeller.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: Inadequate visual lookout by the
driver of the vehicle.
Sequence of Events
Type of Occurrence - Phase of Flight
Cause/Factor - Text
ON GROUND/WATER COLLISION WITH OBJECT - TAXI - FROM LANDING
----- OBJECT - VEHICLE - NOT REPORTED
CAUSE VISUAL LOOKOUT - INADEQUATE - DRIVER OF VEHICLE
Narrative
On March 18, 2000, about 1910 eastern standard time, a Beech 1900, N199GA, and a tug and baggage cart collided while both were being operated on a ramp
at Miami, Florida. The aircraft is registered to Raytheon Aircraft Receivables Corporation, and operated by Gulfstream International Airlines, as flight 9399, a Title
14 CFR Part 121 scheduled domestic passenger flight. Visual meteorological conditions prevailed in the area at the time, and an instrument flight rules flight plan
was filed. The airplane received minor damage, and the airline transport-rated pilot, first officer, and 19 passengers were not injured. The driver of the tug pulling
the baggage cart was seriously injured. The flight originated from Nassau, Bahamas, the same day, about 1800.
The captain's and first officer's written statements showed that they were on their seventh leg of an eight-leg sequence, and had been on duty since 0600.
They had been receiving marshalling instructions and the captain was taxiing the aircraft on the non-ground controlled ramp between concourses F and G, during
heavy rain. According to both flight crewmembers, the ramp area was dark and the aircraft's taxi, navigation and tail floodlights were illuminated. The crew further
stated that the windshield wipers had been operating also, due to the heavy rain at the time. They stated that they had just passed spot number 8, and were
taxiing to the ramp area and could see company ramp personnel. The captain said that the yellow guideline into the ramp area was very difficult to see, but he
was taxiing the aircraft within 10 feet of the line on either side. Both crewmembers said they never saw the baggage employee or his vehicle until after he struck
the left wing, and neither the propeller nor the engine had been stopped until the captain shut down the engine during the normal shutdown sequence at the
ramp. The captain said he saw the baggage handler, and motioned for him to move away, so they could continue taxiing to the ramp and remove the passengers.
According to both crewmembers, it was not until the first officer opened the aircraft door that they both realized that the baggage vehicle had collided with their
aircraft.
The Metro-Dade police report showed that the pilot had indicated that he had been taxiing the aircraft to the company's ramp, northbound in the taxi lane,
when he felt that the left wing had been pushed hard and he observed that the aircraft's left propeller and wing, as well as the rear baggage carts were damaged.
The police report also showed that the baggage cart had been equipped with no lights, only reflectors, and that the distance from the center of the yellow taxi line
to the impact point where the debris lay was about 30 feet. The ramp control incident report showed that the debris was found in front of gate F14 to gate F10, 30
feet from the centerline, and 73 feet from the aircraft containment line.
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