Report: Poor CRM factor in cargo plane takeoff incident (India)

February 28, 2011

Indian investigators concluded that inadequate CRM and a lack of assertion on the part of the first officer were factors in a takeoff incident at Mumbai Airport in June 2010. A Boeing 757 was lined up right of the centreline and k knocked down 15 runway edge lights during the takeoff before the captain was able to steer to the runway centreline.

Blue Dart Aviation Flight No BD-201, a Boeing 757-200F, operated on a cargo flight from Kolkata to Delhi, Mumbai and Bangalore. The flight departed on schedule from Kolkata at 22:25 hrs and was uneventful till Mumbai.

At Mumbai, the aircraft taxied out from Bay No G-4 via Papa, Echo, and was cleared to proceed to holding point N1 for runway 27. The flight was cleared to line up after an arrival of Kuwait Airways Boeing 777 aircraft.

The Captain was PF and the FO was Pilot Monitoring for the departure. While lining up, the Captain lined up on the right of centerline of the runway. The FO promptly drew the attention of the Captain by stating that the centerline was on the left. This was acknowledged by the Captain. On being cleared for take off the thrust levers were opened by the Captain and the aircraft commenced its roll. The FO at this stage called out to the Captain that he was on the right, twice in quick succession. The Captain carried out a correction to the left to return to the centerline. The take off was continued with and the aircraft took off at 05:15 hours at the correct speed and carried out a standard departure. The flight to Bangalore i.e climb, cruise, decent and approach were normal. The aircraft carried out an uneventful landing with FO as PF. The aircraft taxied to the bay at 06:45 hours.

On arrival at the bay, the Engineer observed that there were damages to the right hand wheels. No. 3 main wheel tyre was deflated. There were deep incisions on No.3, 4 & 8 main wheel tyres and reverted rubber on No. 7 tyre. No. 3 brake assembly had signs of FOD and grease nipple was deformed.

At 08:30 hours information was received from Mumbai that a runway inspection was carried out and runway edge lights were damaged. A subsequent report indicated that a total of 15 runway edge lights of runway 27/09 were damaged, nine towards the north side between N1 and N4 and six on the southern side between taxiway E1 and intersection.

The investigators concluded:

The cause for the incident is incorrect lineup by the Captain on the right side of the RW instead of the Center even after being informed by the FO.

Contributory factors: An error in judgement / assessment in determining the extent of displacement to the right of centerline while lining up. Inadequate CRM practices both by the Captain and FO. Lack of assertion on the part of the FO in emphasizing the displacement of the aircraft to the Captain. Inadequate attention on the part of the Captain towards inputs from the FO.

More information:

NTSB: Auto speed brake mechanism anomaly noted in Jackson Hole runway excursion incident

January 12, 2011

The NTSB issued a second investigation update regarding the runway overrun of a Boeing 757 in Jackson Hole, Wyoming.

At about 11:38 am MT onDecember 29, American Airlines flight AA2253, a Boeing 757-200 (N668AA) inbound from Chicago O’Hare International Airport, ran off the end of runway 19 in snowy conditions while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board.

Instrument Flight Rules (IFR) weather conditions prevailed around the time of the incident with a ceiling of 400 feet, light snow and visibility of 1 mile. Winds were 10 knots from 240 degrees.

The NTSB did not find any discrepancies  in the air/ground, autobrake, and thrust reverser systems. Examination of the auto speed brake mechanism in the cockpit pedestal found that the linear actuator aft attachment was improperly installed and was missing a bushing. This loose connection allowed the cam to be rotated slightly relative to the switch, which could cause the switch roller and the notch in the cam to not always align. System operation with this condition present is being investigated.

The flight data recorder readout revealed the following factual information:

  • The FDR download contains the last 43.9 hours of data, more than the required 25 hours, and includes all of the incident flight.
  • The recorded speed brake handle position indicates that the speed brakes were manually extended by the flight crew during the approach after which the handle was left in the armed position until landing. The FDR records only the speed brake handle position and not the individual speed brake (spoiler) panel positions.
  • The FDR data indicate that the aircraft touched down at approximately 132 knots.
  • At touchdown, the air/ground parameter changes to “ground” for approximately one second and then switches to “air” for approximately ½ second before changing back to “ground” for the remainder of the recording.
  • During the time period when the air/ground parameter switched back to “air,” the speed brake handle position momentarily moved toward the down position and then returned to the armed position where it stayed for the remainder of the recording.
  • Thrust Reverser (T/R) discrete parameters indicate that the T/Rs moved into the in-transit position during the ½ second that the air/ground logic parameter indicated “air.”
  • The T/Rs remained in the in-transit position for approximately 10 seconds before transitioning to the stowed position for one second. The T/Rs then moved back to the in-transit position for an additional 6 seconds before becoming deployed.
  • The T/R discrete parameters indicate that approximately 18 seconds elapsed from the time the T/Rs began moving until they were fully deployed.

The investigation is continuing.


Boeing 757 runway excursion incident at Jackson Hole, WY

December 30, 2010

The U.S. National Transportation Safety Board (NTSB ) has opened an investigation into an incident in which a Boeing 757 passenger jetliner departed the runway while landing at Jackson Hole Airport in Wyoming.

At about 11:38 am MT on December 29, American Airlines flight AA2253, inbound from Chicago O’Hare International Airport, ran off the end of runway 19 while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board.

The aircraft came to rest in hard packed snow about 350 feet beyond the runway overrun area. The weather was reported to be snowing at the time of the incident. No damage to the aircraft has been reported. Runway 19 is a 6300 ft asphalt runway.  A video made by a passenger (note: the video is no longer online) during landing shows the thrust reversers were deployed when the airplane was approximately abeam the terminal building, which is about 4000 feet down the runway.

The airplane involved in the mishap was N668AA.

More information:

NTSB issues update on its investigation of Boeing 757 windshield fire

May 21, 2010

In its continuing investigation of a fire aboard a Boeing 757 that diverted to Dulles Airport (IAD) enroute to the Los Angeles International airport (LAX) from New York’s John F. Kennedy International airport (JFK), the National Transportation Safety Board (NTSB) has developed the following factual information.

On Sunday, May 16, 2010, about 21:17 the pilots on United Airlines flight 27, a Boeing 757-222, N510UA, noted a strong acrid smell and observed smoke from the Captain’s lower front windshield.  The incident occurred about 30 minutes into the flight while the aircraft was level at 36,000 feet MSL.   On board the aircraft were 7 crew members and 105 passengers.

The Captain and First Officer reported that they donned their oxygen masks and smoke goggles immediately after observing the smoke and fire. The Captain then gave control of the airplane to the First Officer and discharged a halon fire extinguisher. The smoke and fire dissipated but then re-ignited. The Captain obtained a second bottle from the Purser.  The fire remained extinguished after this second bottle was discharged. At approximately 500 feet MSL on final approach to Runway19L at IAD, the Captain’s windshield cracked. The landing was uneventful. The airplane cleared the runway, after which ARFF (Aircraft Rescue Firefighting) entered the aircraft to check for residual heat and fire. None was found and the airplane was towed to the gate for deplaning. There were no evacuation and no injuries to the flight crew or passengers.

Preliminary examination of the cockpit area revealed that the inner pane of the Captain’s windshield had cracked. One of the five terminal blocks attached to the inside of the lower left windshield was consumed by fire and the portion of the wire harness associated with this terminal block was significantly damaged by fire. There was significant sooting and paint peeling to the left hand side of the windshield air frame support.

The Captain’s windshield was moved and will be examined by Board investigators at the manufacturer.

Two previous windshield fire events on B757-200 aircraft prompted the NTSB to issue Safety Recommendation A-07-50  The Safety Board investigators will look closely at the recovered hardware to determine if this latest event is related.

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