National Transportation Safety Board - Aircraft Accident/Incident Database

Transcription

1 Incident Rpt# WPR10IA430 08/26/ PDT Regis# N590JB Sacramento, CA Apt: Sacramento International SMF Acft Mk/Mdl AIRBUS A Acft SN 2231 Acft Dmg: MINOR Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl IAE V2527-A5 Acft TT Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 121 Opr Name: JETBLUE AIRWAYS CORP Opr dba: On August 26, 2010, about 1251 Pacific daylight time, an Airbus , N590JB, experienced an abnormal landing at the Sacramento International Airport (SMF), Sacramento, California. During touchdown and landing rollout on runway 16R, the airplane rapidly decelerated; the main landing gear tires blew out, and a minor tire-related fire erupted. All of the airplane's occupants, emergency evacuated by use of the cabin door slides. The airplane sustained minor damage. The two airline transport pilots, three flight attendants and 79 passengers were not injured. Seven passengers received minor injuries during the evacuation process. The airplane was registered to and operated by JetBlue Airways as flight number 262, under the provisions of Title 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The scheduled domestic passenger flight originated about 1141 from the Long Beach Airport, Long Beach, California. According to the flight crew, the flight and approach to runway 16R were normal. The first officer was the pilot flying. Upon touchdown, the airplane began a rapid deceleration, and the first officer remarked to the captain that it felt like a main landing gear tire blew out. About this time, air traffic control tower personnel reported observing sparks and smoke in the area of the main landing gear. The captain took control of the airplane and maintained directional control as the airplane came to a stop about 2,000 feet from its touchdown point. The captain directed the first officer to initiate the Quick Reference Checklist (QRC) for ground evacuation, up to the evacuation decision point. At that time, air traffic control tower personnel confirmed smoke and fire were still visible around the main landing gear. Based on this information the captain elected to evacuate the airplane. Crash fire rescue personnel and equipment responded to the airplane, which was stopped on the runway. According to the flight crew and flight attendants, a swift and orderly evacuation was performed via emergency evacuation slides at both the forward main cabin doors and the rear left door. The rear right door was not used since a flight attendant observed smoke in the vicinity. The airplane was subsequently examined by the operator and Federal Aviation Administration (FAA) personnel. Airplane damage was limited to four deflated main landing gear tires and the wheel rims were ground down. The main landing gear tires showed evidence of being locked on touchdown. Ground damage was limited to minor grazing of the runway's surface. The airplane's Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR) were removed for analysis. The DFDR was examined by the operator and the National Transportation Safety Board (NTSB). According to the airplane's recorded flight data, the parking brake had become engaged in flight during the landing approach at approximately 5,116 feet mean sea level, and remained engaged throughout the remainder of the flight and landing roll. The parking brake activation occurred about the same time the autopilot was disconnected. The downloaded data indicated that the airplane was being configured with speed brakes about 4 seconds prior to the parking brake activation. The first officer stated that he activated the speed brakes. The airplane controls for the speed brake and parking brake are located in the center console in the near vicinity of each other. The speed brake lever is on the left side of the console and is activated by pulling the lever. The parking brake switch is on the bottom center of the console and is activated by pulling and rotating the switch. The CVR was examined by the NTSB Vehicle Recorder Division. The airplane's CVR revealed no sounds of the associated warning audio for the parking brake activation or autopilot disconnect. The CVR did reveal sounds captured around the time of the parking activation, however, the source of the sounds proved to be inconclusive. Non-essential communication existed during the sterile cockpit portion of the descent and approach. During interviews with the flight crew, neither pilot recalled any abnormal indications or cockpit warnings associated with the parking brake system prior to landing. The Electronic Centralized Aircraft Monitoring (ECAM) system is designed to monitor and advise the flight crew of the airplane's status. According to the manufacturer, if the parking brake is engaged in flight, the ECAM illuminates the master caution light, a single chime audio associated with the master caution light is given after a 3 second delay, and a parking brake on advisory message is presented. At 800 feet above ground level (agl), the alerts associated with the parking brake selected on in flight, are reactivated by the ECAM, in the event the alert or master caution was cleared by the flight crew. The applicable hydraulic system also provides an indication that the parking brake was activated in flight by the braking pressure indicators becoming operational. However, normal checklists do not require an in flight check of the brake pressure indicators. The operator performed an examination and functional test of the airplane's parking brake system and central warning systems in accordance with the manufacturer's maintenance manual, with no abnormalities noted. The parking brake control switch was also functionally checked by the operator with no Page 1 Copyright 1999, 2012,

2 abnormalities noted. A vendor conducted an examination and breakdown of the parking brake control valve and control switch with no abnormalities noted. On a follow up interview, the first officer described his personal technique where he would preempt the autopilot disconnect audio by selecting the ECAM emergency cancel pushbutton prior to disconnecting the autopilot and would hold it for several seconds afterwards. The autopilot disconnect warning audio (cavalry charge) is temporary and last a maximum of 1.5 seconds, if the autopilot is disengaged using standard procedures. Selection of the ECAM emergency cancel pushbutton would terminate the autopilot disconnect audio and any other present caution (master caution lights, ECAM alert message) for the rest of the flight. The alert would appear in the cancelled caution field on the status page and could be recalled if necessary. The operator's procedure has a note to use the ECAM emergency cancel pushbutton only for spurious master cautions. According to the manufacturer, if the ECAM emergency cancel pushbutton is selected prior to the parking brake on alert being displayed; the master caution light and single chime associated with the parking brake on alert would be inhibited. In addition, at 800 feet agl, the "parking brake on" alert message and master caution would not be reactivated. The ECAM emergency cancel pushbutton is not a parameter recorded by the DFDR. Page 2 Copyright 1999, 2012,

3 Accident Rpt# CEN14LA103 01/05/ CST Regis# N430CT West Delta 109, GM Apt: West Delta 109 WD10 Acft Mk/Mdl BELL 430 Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Prelim Prob Caus: Pending Eng Mk/Mdl ROLLS-ROYCE 250-C40B Acft TT Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: CHEVRON U S A INC Opr dba: On January 5, 2014, about 1000 central standard time, a Bell 430 helicopter, N430CT, sustained substantial damage during landing when the tail rotor struck a handrail on the crane davit on the West Delta 109 oil platform located in the Gulf of Mexico. The pilot and passenger were not injured. The helicopter was owned and operated by Chevron USA Inc., under the provisions of the 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed at the time of the accident. The helicopter departed the MP313 oil platform about 0930, and was on a company visual flight rules flight plan. Page 3 Copyright 1999, 2012,

4 Accident Rpt# CEN14LA053 10/12/ CDT Regis# N368PK Lincoln, NE Apt: Lincoln LNK Acft Mk/Mdl CESSNA 525A Acft SN 525A0448 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl WILLIAMS FJ44-3A-24 Acft TT 290 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: EXECUTIVE FLIGHT SERVICES, INC Opr dba: EXECUTIVE AIRSHARE On October 12, 2013, about 1640 central daylight time, a Cessna 525A, N368PK, experienced a bird strike to the right wing during climb from Lincoln Airport (LNK) near Lincoln, Nebraska. The airplane sustained substantial damage to the outer right wing spar. The airline transport pilot and copilot were uninjured. The airplane was registered to Cessna Aircraft Company and operated by Executive Flight Services, Inc. (dba Executive AirShare) under 14 Code of Federal Regulations Part 91 positioning flight that was operating on an instrument flight rules flight plan. Visual meteorological conditions prevailed for the flight that departed at 1636 and was en route to Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The positioning flight departed LNK, elevation 1,218.6 feet mean sea level (MSL), from runway 36 (12,901 by 200 feet, asphalt/concrete) and climbed to an initial altitude of 3,000 feet MSL and contacted LNK air traffic control departure. Departure control issued a climbing clearance to 10,000 feet MSL and a right turn to approximately 060 degrees. The flight crew made the right turn and began a climb to 10,000 feel MSL. During the climb and after passing approximately 6,400 feet MSL, the flight crew noted a flock of birds that they described as "snow geese." The flight crew reported that they were unable to avoid the approximately birds and struck one of them at the right outboard wing while the airplane was 7-8 miles northeast of LNK. The estimated indicated airspeed of the airplane at the time of the birdstrike was 200 knots. After noting the wing damage and verifying the engines, controllability, and overall airplane condition were operating normal, the flight crew informed LNK [air traffic control] that they had experienced a bird strike and would need to return to LNK. They were issued vectors back to the longest runway, runway 36, where they landing without further incident. The Airport Facility Directory for LNK states within the Airport Remarks section that there are birds in the vicinity of the airport. The Aeronautical Information Manual, Section 7-4-1, Migratory Bird Activity, states in part: a. Bird strike risk increases because of bird migration during the months of March through April, and August through November. b. The altitudes of migrating birds vary with winds aloft, weather fronts, terrain elevations, cloud conditions, and other environmental variables. While over 90 percent of the reported bird strikes occur at or below 3,000 feet AGL, strikes at higher altitudes are common during migration. Ducks and geese are frequently observed up to 7,000 feet AGL and pilots are cautioned to minimize en route flying at lower altitudes during migration. The United States Avian Hazard Advisory System (USAHAS) program objective was to develop a predictive Avian Hazard Advisory System using Geographic Information System (GIS) technology as a key tool for analysis and correlation of bird habitat, migration, and breeding characteristics, combined with key environmental and man-made geospatial data. The Avian Hazard Advisory System indicated a moderate risk at the time of the accident. Identification of bird species involved in bird/aircraft strikes is an important part of the overall assessment and management of this complex issue. Knowing the exact species provides guidance to the size, behavior, and ecology of the bird in question and is key to tracking species trends as well as focusing preventative measures. Species identifications provide the baseline data needed to plan habitat management on airfields, build avoidance programs, and have even been used to assist engineers to design windscreens and engines that are more resilient to birdstrike events. Bird remains were collected by the United States Department of Agriculture to the Smithsonian Institution, Feather Identification Lab. DNA analysis and microscopic examination identified the bird remains as American White Pelican. According to the National Audubon Society, the American White Pelican is one of North America's largest birds, the American White Pelican is distinctive for its nine-foot wingspan, conspicuous white body, and the improbable proportions of its large bill and pouch. Despite their size, the pelicans are graceful fliers, with flocks soaring high in the air and wheeling in unison. American White Pelicans may be seen cooperatively foraging in shallow waters, or at adjacent loafing sites. American White Pelicans weigh about 16.4 pounds (7,500 grams), and measure over five feet in length, with a huge 9-foot wingspan. Sexes look similar, with Page 4 Copyright 1999, 2012,

5 short legs and tail; long, broad white wings with black tips and trailing edges; a large, heavy all-white body; and a huge pinkish to paleorange bill and throat pouch. The American White Pelican resides mainly in western and southern portions of North America, breeding in colonies in inland scattered locations from western Manitoba and Minnesota westward to northern California. The birds winter along the warm southern coasts of California, Mexico, the Gulf Coast, and Florida. In breeding season, American White Pelicans are found mostly inland, nesting on isolated islands in lakes, and feeding on shallow lakes, rivers, and marshes, which may be far from nesting sites. They also breed locally on coastal islands. The birds winter mainly along coasts, in shallow, protected bays and estuaries, and on large lakes in warm climates. Migrating flocks of pelicans rest on lakes and rivers along the way. According to the Smithsonian Institution, Feather Identification Lab. Reporting every wildlife strike is crucial to the continuing effort of birdstrike prevention. Equally important is to assign an accurate species to each case so the overall data is complete and can be correctly interpreted. Although commercial aviation currently reports about 7,500 strikes per year (Wildlife Strikes to Civil Aircraft in the United States (PDF), Dolbeer et al.), very few of these cases are associated with a specific identification of the wildlife involved. Methods used by the Smithsonian Institution's Feather Identification Lab - as well as links and recommendations for reporting, collecting, and shipping birdstrike material is available at the following link: The airplane was not equipped with a flight data recorder or a cockpit voice recorder. The Cessna Aircraft Company AReS 1 maintenance recorder, part number , serial number 1118, recorded the airplane's last flight on September 27, 2013, and did not record any subsequent flights. It was unknown why any later flights were not recorded. Page 5 Copyright 1999, 2012,

6 Accident Rpt# WPR14LA084 01/01/ PST Regis# N133GC Boulder City, NV Acft Mk/Mdl EUROCOPTER EC 130 B4-B Acft SN 3883 Acft Dmg: SUBSTANTIAL Rpt Status: Prelim Prob Caus: Pending Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: PAPILLON AIRWAYS INC. Opr dba: On January 1, 2014 about 1507 Pacific standard time, a Eurocopter EC-130, N133GC, landed hard during an autorotation, while on short final at the Boulder City Municipal Airport (BVU), Boulder City, Nevada. The commercial pilot was the sole person on board and was not injured. The helicopter came to rest on its right side and sustained substantial damage to the fuselage and tail boom. The aircraft was registered to Zuni LLC, and operated by Papillon Airways, Inc., under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the postmaintenance check flight. No flight plan was filed for the local flight that departed about In a written statement, the pilot reported that she completed the post-maintenance operational check flight and was on short final to BVU, about 200 feet above the ground with an airspeed of 40 to 50 knots. Shortly thereafter, the fuel pressure indicator light illuminated and the engine "flamed out". The pilot stated that she lowered the collective to initiate an autorotation, but did not have the airspeed to successfully complete it. The helicopter's tailboom impacted the ground first during the accident sequence, followed by the hard landing. The helicopter's skids separated and the fuselage sustained substantial damage. The helicopter was relocated to a secured area for further examination. Page 6 Copyright 1999, 2012,