1 WASHINGTON, D.C z AIRCRAFT ACCl ENT REPQRT AMERNAN AIRLIWES, INC., E DC-10-10, NllOAA CHICAGO-B'HARE INTERNATIONIIL AIRPORT CHICAGO. 1ltfMftS. I $1 UNITED STATES GGVERNMENT i,.
2 TECHNICAL REPORT WCUMKNTATION PAGE. Report No. 2.Government Accession No. ).Recipient's Catalog No. msb-aar Title and Subtitle Aircraft Accrdent Report- 5.Report Date Ameriean Airlines, Inc. DC-10-10, December NllOAA. Chicarro-O'llare International Airoort 6.Peiforming ~. Organization Chicago; IUinoik Mav I Code. Authorts) I 8.Performing Organization Report NO.. Performing Organization Name and Address IO.Uork Unit No E National Tnmsportation Safety Board II.Contract or Grant NO. Bureau of Accident Investigation Washington, D.C Type of Report and Period Covered 2.Sponroring Agency Name and Address Aircraft Accident Report May 25, 1979 NATIClNAL TRANSPORTATION SAFETY BOARD Washington, D. C Sponsoring Agency Code 15.Supplementary g'otes i6.abstract About 1504 c.d.t., Nlny 25, 1979, American Airlines, Inc., Flight 191. a McDonnell-Douglas DC aircraft, crashed into an open field just short,of a troiler park about 4,600 ft northwest of the departure end of runway 32R at Chicago-O'Haru International Airport, Illinois. Flight 191 was taking cff from runway 32R. The weather was clear and the visibility was 15 miles. i takeoff rotation. the left assemb!v an- 2 ft o w i n n left wi ne separated huathc w n d fell to the runway. Flight 191 continued to climb to about 325fft above the ground and then began to roll to the left. The aircraft continued to ro to the left until the wings were past the vertical position, and during the roll, the aircraft's nose pitched down below the hcrizon. Flight 191 crashed into the open field and the wreckage scattered into an adjscent trailer park. The aircraft was destroyed in the crash and subsequent fire. T w n e d and seventv-on? oersons on board Flight 191 were killed; two persons on the ground were killed. and two others were injured. An old aircraft hangar, several automobiles, and a mcbile home were destroyed. The National Transportation Safety Board determines that the probable cause of this accident was the asymmetrical stall and the ensuing roll of the aircraft I7,,. Y..- ou, YnrAc DC-10; loss of control; asymmetrical stad; stal! warning system; slat disagreement warning light; structural separation; No. 1 engine and Pylon;.. design criteria: maintenance Drocedureg FAA regulations; industry communications procedures. I. z Ii8.0istribution Statement his document is available to he public through the ational Technical Informa- bonservk?:?pringfield, vlrglnla ZZI~I 1 9. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i 20.Security i~ f~ i C:assification ~ ~ t i ~ 21.No. ~ of Pages 22.Price (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED 103 NTSB Form (Rev. 9/74)
3 because of the uncommanded retraction of the!eft wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems psu'txfrom maintenance-induced damage leadina to the scparation of the No. 1 tin2 takeoff. The separation rehed frogdemage by hproper mainteiance procedures which led to failure of the pylon'structure. Contributing to the cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design. of the leading edge slat system to the damage which produced asymmetry; deficiencies in Federal Aviation Administration surveillance. and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminele the particulars regarding previous maintenance damage incidents; and the intolerance. of prescribed operational procedures to this unique emergency. z
4 ~~ CONTENTS 1 Synopsis History of the Flight... 2 s to Persons... 3 Y.3 Damage to Aircraft... Other Damage Fersonnel Information... 3 k. 6 Aircraft Information hleteorological Information... 3, ' 1.8 Aids to Navigation... unications Aerodrome Information... 4 'S Wreckage and Impact Information Medical and Pathological Information Fire Survival AspecLs n Stress Tgsting of the Pylon Aft Bulkhead Wind 'runnel and Simulator Tests... ;' 22 Information Air Carrier Maintenance Procedures... L FAA Reporting & Surveillance Procedures... " Msnufaciurer's Production kina Procedures...., DC-10 Electrical & Hydraulic Systems Flightcrew Procedures...! Analysis Conclusioris Findings Probable Cause Safety Recommendations Appendixes Appendix C. Aircraft Information Appendix D. ISreckage Diagram Appendix E.. Pertinent Airworthiness Regulations... Appendix F. Applicable Airworthiness Directives Appendix G. Suspension and Kestoratioll of DC-10 Type Certificate Appendix H.DFDR Readout... 98
5 NATIONAL TRANSPORTATION SA.FETY BOARD WASHINGTON, D.C Adopted: December 21,1979 AI3CRAFT ACCIDENT KEPORT AMERICAN AIRLINES, INC. DC-10-10, NIIOAA CHICAGO-O'HARE 1NTEKNATIONAL AIRPORT CHICAGO, ILLINOIS MAY 25, 1979 SYNOPSIS About 1504 c.d.t., May 25, 1979, American Airlines, Inc., Flight 191, a McDonneU-Douglas DC aircraft, crashed into an open field just short of a trailer park about 4,600 It northwest of the departure end of runway 32R at Chicago-O'Hare International Airport, Illinois. ', Flight 191 was taking off from runway 32H. The weqher was clear and the visibility was 15 miles. During the takeoff rotation, Me left engine and pylon assembly and about 3 ft of the Icading edge of the left wing separated from the aircraft and fell to the runway. Fhght 191 continued to climb to about 325 ft above the ground and then began to roll to the left. The aircraft continued to roll to the left until the wings were past the vertical position, and during the roll, the ~., aircraft's nose pitched down below the horizon. Flight 191 crashed into the open field and the wreckage scattered into an adjacent trailer park. The airet'aft was destroyed in the crash and subsequent fire. Two hundred and seventy-one persons on board Flight 191 were killea two persons on the ground were killed, and two others were injured. An old aircraft '* hangar, several automobiles, and a mobile home were destroyed. The National Transportation Safety Board determines that the probable. cause of this accident was the asymmetrical stall and the ensuing roll of the aircraft because of the uncommanded retraction of the left wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems resultingfrom mnintenance-induced damage leading to the separation of the No. 1 engine and pylon assembly at a critical point during takeoff. The separation resulted from damage by improper maintenance procedures which led to failure of the pylon structure. Contributing to the-cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design of the leading edge slat system to the damage which produced asymmetry; deficiencies in Federal Aviation Administration surveillance and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminate the particulars regarding previous maintenance damage incidents; and the intolerance of prescribed operational procedures to this unique emergency.
6 -2-1. FACTUAL INFORMATION 1.1 History of the Flight At 1459 c.d.t.,- 11 May 25, 1979, American Airlines, Inc., Flight 191, a McDonnell-Douglas DC-10 series 10 aircraft (DC-10-10) (NLIOAA), taxied from the gate at ChicagwO'llare International Airport, Illinois. Flight 191, M regulnrly scheduled passeoiger flight, was en route to Los Angeles, Californie, with 258 passengers and 13 crewmembers on board. Rlaintenance personncl who monitored the flight's engine start, push-beck, and start of taxi did not observe anything out of the ordinary. I The weather at the time of departure was clear, and the reported surface wind was 020"at 22 kns. Flight 191 was cleared to taxi to runway 32 right (32K) for takeoff. The company's Takeoff Data Card showed that the stabilizer trim setting was So aircraft noseup, the takeoff Gap setting was loo, (ind the takeoff gross weight was-379,000 lbs. The target low-pressure compressor (N ) rpm setting was 99.4 percent, critical engine failure speed. (V ) was 139 ',k& indicated airspeed (KIAS), rotation speed (VK) was 145 KIM, and takeoff safety speed (V,) was 153 KIAS. %. Flight 191 was cleared to taxi i.nto position on runway 32R and hold. At 1502:38, the flight was cleared for takeoff. nnd at 1502:46 the captain ncknowled: ged, "American one nitiety-one under way." Company personnel fnmilinr with the flightcrew's voices identified the captain as the person making this cnll end the ensuing V1 and VR speed callouts on the cockpit voice recorder (CVH). The takeoff roll was normal until just"before rotation at which time sections of the left, or No. 1, engine pylon structure came off the hircrnf't...witnesses saw white smoke or vapor coming from the vicini$p.g! thc No. I, engine *; pylon. DuF& rotati,ge- 1 engine a_n~~y~-~etd.-frpm_lhe a- over-che top of the wme%dlell to the runway. Flight 191 lifted off about 6,000 ft down runway 32K, climbed out in a wings-level attitude, and reached an altitude of about 300 It above the ground (a.g.1.) with its wings still level. Shortly thereafter, the aircraft began to turn and roll to the left, the nose pitched down, and the aircraft began to descend. As it descended, it continued to roll left until the wings were past the verticnl position. Flight 191 crashed in an open field and trailer park about 4,680 ft northwest of the departure end of runway 32K. The aircraft was demolished during the impact, explosion, and ground fire. Two hundred and seventy-one persons on board Flight 191 were killed, two persons on the g-ound were killed, md two persons on the ground sustained second- ana third-degree bwns. The aircraft crashed about 1504, during daylight hours; the COOrdinHteS of the crnsh site were 42%0'35"N, 8755'45"W. - l! All times herein are central daylight time, based on the 24-hour clock.
7 Injuries to Persons llljuries -- Crew Passengers Others Fatal Seriom MinorlNone Damage to Aircraft The aircraft was destroyed. 1.4 Other Damage An old aircraft hangar, several automobiles, and a mobile home were destroyed Personnel lnformation * All flight and cabin personnel were qualified. (See appendix B.) 1.6 Aircraft Information Flight 191, a McDonnell-Douglas DC-10-10, NllOAA, was owned and operated by American Airlines, Inc., and was powered by three General Electric CF6-6D engines (See appendix C.) According to the manufacturer, e-hed 11,512 :bj,f~~.i.l..855 lbj,.&r,. a With the loss of the engine pylon structure, the.+ircraft's center of gravity (c.g.) moved aft 2 percent to about 22 percent mean aerodynamic eherd (MAC). The resultant c.g. was within the forward (16.4 percent MAC) and aft (30.8 percent MAC) c.g. limits. The lateral c.g. shift was 11.9 inches to the right. 1.7 Meteorological Information At the time of the accident, the weather at the airport was clear. The surface observations at O'Hare International were as follows: 1451, surface aviation: Clear, visibility-15 mi, weather-none, temperature--63"f, dewpoint--299, winds020'at 22 kns, altimeter inhg , local: Clear, visibility--15 mi, weather--none, temperat~re--63~ F, dewpoint--29' F, winds--020 at 19 kns gusting to 28 kns, altimeter inhg., remarks--aircraft mishap Aids to Navigation Not applicable. *,
8 1.9 Communications There were no known communications malfunctions Aerodrome Information ChicagcrO'Hare International Airport is located 16 mi northwest of downtown Chicago, Illinois, and is served by seven runways. Runway 32R is 10,003 ft long and 150 ft wide, and has a concrete surface.' The runway elevation is 649 ft mean sea level (m.s.1.) at its southeast end and ti52 It m.s.1. at its northwest end Flight Recorders The aircraft was equipped with a Fairchild Model A-100 CVR, serial No The CVK was recovered and brought to the Safety Board's laboratory where a transcript of the recording wns prepared. The recording was Incomplete because of the loss of electrical power to the recorder during aircraft rotation. However, the aircraft's gross weight, stabilizer trim setting, V1, end VR cailouts ' were recorded. z The aircraft was equipped with a Sundstrand digital flight data recorder (DFDR), serial no The recorder had been damaged structurally, but there was no fire or heat damage. The recording tape' was broken; upon removal from the recorder the tape was spliced together and a readout was made. Two 6-sec areas of data were damaged because of the breaks in the tapes; however, most of these data was recovered. 8 The DFDR recorded 50 sec of data during the takeoff roll and 31 sec of airborne data before the recording ended. (See appendix ti.) The DFDR readout showed that the stabilizer trim setting for takeoff was 6.5O aircraft noseup. The DFDK's tolerance for this parameter is + lo. Because of unusual aircraft attitudes' during the last few seconds of the fligtit, the recorded altitude and airspeed data were not correct. Therefore, the DFUR altitude and indicated airspeed values cited hereaiter have been corrected for the position errors resulting from the aircraft's attitudes during the last few seconds of the descending flight. Correlation of the DFDR and CVR recordings. disclosed that the.. flightcrew had set the flaps and stabilizer trim at loo and about 5' aircraft noseup, respectively, for takeoff. A rolling takeoff was made, takeoff thrust was stabilized at EO KIAS, and left rudder and right aileron were used to compensate for the right crosswind. The V and V callouts were made about 2 sec after these speeds were recorded by the DhDR. &e elevator began to deflect up at VR. The aircraft began to rotate upward immediately and continued upward at a rate of 1.5' per sec. Flight 191 accelerated through V speed during rotation and before it lifted off the ranway. The last stable tat?eoff thrust on the No. 1 'engine was recorded 2 sec before liftoff. One second later, the word "damn" was recoraed on the CVR, and then the CVR ceased operating. Onr second before llftoff and simultaneous with the loss of the CVR and the No. 1 engine's parameters, the DFDR ceased recording the positions of the left inboard ailero,:.: left inboard elevator, lower rudder, and Nos. 2 and 4 left wing leading edge slats. The DFDK continued to record ali other parameters b
9 -5- including the position of the upper rudder, the outboard aileron, the outboard elevator, and the No. 4 leading edge slats on the right side of the aircraft. The electrical power for the CVK and the sensors for the lost DFDH functions were all derived from the aircraft's No. 1 e.c. generator bus. Flight 101 became airborne about 6,000 ft from the start of the takeoff roll and remained airborne for 31 sec. It lifted off at V2 + 6 KIAS and at 10" pitch attitude. Twoseconds after liftoff, the UFDR reading for the No. 1 engine's N1 was zero, the No. 2 engine's N speed was increasing through 101 percent, and the No. 3 engine's N1 was essentidy at the takeoff setting. The flight lifted off in a slight left wing-down attitude. Application of right wing-down aileron and right rudder restored the flight to a wings-level attitude and the headlng was stabilized between 325' and 327'. The flight maintained a steady climb about 1,150 feet per minute (fpm) at a 14' noseup.p~tch attitude--the target pitch'attitude displayed by the Ilight director for a twoengine climb. During the climb, the No. 2 engine N speed increased graduallj from 101 percent to a final value of 107 percent; the do. 3 engine N speed did not cllangf appreciably from the takeoff setting. During the initid par#ibf the climb, the aircraft accelerated to 8 maximum speed of 172 KIAS; it reached this value about 9 sec after liftoff and about 140 ft a.g.1. Flight 191 continued to climb about 1,100 fpm. The pitch attitude and heading were relatively stable. Right wing-down aileron and right rudder were used lo control and maintain the heading and the roll altitude during the climb in... the gusty right crosswind. During the climb, the aircraft began to decelerate from 172 KIAS at an average rate 01 about 1 kn per second. At 20 sec after liftoff, at 325 ft a.g.1. and 159 KIAS, the flight began to roll to the left and passed through 5O left wing down. The left roll was accompanied by incqeasing right-wing-down aileron deflection. At this point, the previoudy stabilized right rudder deflected suddenly to zero, remainec' at zero for I sect and then moved toward its previous deflection. The flight began to turn to the left, and the left roll incrpsed even though increasing right rudder and right-wing-down aileroc deflections were being applied. At 325 ft a.g.1. the flight had turricd through the runway heading and was rolling to the left at 4' per second. The right rudder deflection increased during the turn. The previously stable pitch attitur'c began to decrease from 14O even though the elevator was being increased to the full aircraft noseup deflection. The maximum pitch rate of about 12'pCr second was reached just before the crash. rudder and right-wing-down aileron deflections. Three seconds before the end of Flight 191 continued lo roll and turn to the left despite increasing right the DFDK tape, the aircraft was in a YOo left bank and at a O'pitch attitcde. The DFUR recording ended with the eircraft in '1eft roll and M 21'nosedown pitch attitude with full counter aileron and rudder controls $nd nearly full up elevator being applied. 1
10 DFDR longitudinal and vertical acceleration data were integrated to determine the headwind components at points where the aircraft attained certain speeds and where it lifted ofl; to establish an altitude profile; and to determine the location where the DFDK stopped. These data showed that the DFDK ceased operation 14,370 ft from the southeast end of runway 32R and 820 ft left of tke runwny's extended centerline. Examination of the crash site showed that the first point of impact was 14,450 ft beyond the southeest end of runway 32R and 1,100 It left of its extended centerline. Based on these data and the corrected altitudes, the DFDK ceased operating at impact. The flight reached a maximum altitude of 350 ft a.g Wreckage and Impact Information Flight 191 struck the ground in a left wing-down and posedown attitude. The left wingtip hit first, anc! the aircraft exploded, broke apart, and was scattered into an open ficld and n trailer park. The disintegration of the aircraft structure was so cxtcnsivc that little useful data were obtainetl from postimpact examination of the wreckage with the cxccption of the No. 1 pylon, which 'vas found off the right side of runway 32K. (See figure 1.) Investigators located and documented identifiablc aircraft components. Except for the No. 1 enginc nnd pylon, portions of the enginc cowling, and a part of the leading edge of the wing directly nbove the pylon, the aircraft wreckage came to rest in the open field and trailer park. (See appendix D.) The first marks made by engine contact of the No. 1 engine an3 pylon with. the runway began about IY It to the right of the ccnterline lights tind about 6,953 ft beyond the southeast end jf rtinhay Other parts of cngine and pylon structure were located in this aren; however, no spoiler artuators or hydraulic lines were found. The pylor is attached to lhc wing using Spherical ball joints in three different structural elements. Two of the spherical joints are aligned vertically in a forward bulkhead which is ettnched to structure in the wing forward of the front spar. Another spherical joint behind the forward bulkhead transmits thrust loads from pylon structure into a thrust link which in turn is connected through another spherical joint to structure on the lower surface of the wing. The third atbachment point is a spherical joint in the pylon aft oulkhcad which attaches,'to a clevis mounted on the underside of the wing. The pylon forward bulkhead and portions Gf the flange irom the pylon oft bulkhe3d either remained with the separated No. 1 pylon or wcre scr'tercd along the runwny. (See figures 2 and 3.) The No. 1 pylon's aft clevis attach assembly and portions of the pylon aft bulkhead, wing thrust angle assembly nnd thrust link, and pylon forwnra bulkhead attach assembly remained with the wing. The pylon forward bulkhead was bent forward about 30'and most of the bolts which held the bullillcad upper plates were m.issing. Thc upper 12 inches of the forward plate were bent forward an additional 10' to 15'. The aft plate Was broken below the thrust fitting connection, and a iarge piece of the upper left corner was missing.. &
14 -10- The wing's forward support fitting, which attached the pylon forward bulkhead to the wing at the upper and lower plugs and spherical bearings, was found at the main wrechage site. The upper and lower plugs and their attaching hardware were intact, and the upper and lower spherical bearings were attached to the fitting. The pylon thrust fitting remained attached to. the forward portion of the pylon's aft upper spar web. The pylon thrust link, which attached the pylon thrust fitting to the wing thrust angles, was found at the main wreckage site attached to a portion of the wing thrust angles. Its forward spherical bearing was cocked to the exlreme left, and a segment of the bearing which had broken away WBS found on the runway. The thrust bushing bolt had broken in two parts, both of which wzre found in the grass adjacent to the runway. The bolt nut was attached to one of the broken pieces, and the faces of the nut were gouged severely. Except for one lubrication rstainer washer, which was not found, thc remniqing portions of the thrust bushing bolt assembly were found along the runway. ' One shim spacer fro,,, the assembly was crushed severely while the other was relativqly undrhlaged. The upper two-thirds of the pylon aft bulkhead separated from the flanges around its periphery and wcs found in the wrerkage. The top two pieces of its attach lugs had separated from the bulkhead, and the eft skie of the bulkhead was gouged heavily near the lower edge of the wing clevis lug, which attache0 the aft bulkhead to the wing. The WIAL clevis was attached to the wing. The aft bulkhead's spherical bearing was attachcd to the clevis, tad thc separated pieces of 4 the aft bulkhead's attach lugs were found on top of the spherical bearing. The Nos. 2 and 3 engines were located in the main wreckage., The damage to the engines indicated that they were operating at high rpm at impact. AU three engines were taken to the American Airline's Maintenance Facility at Tulsa, Oklahoma, where they were torn down and examined. There was no evidence of any preimpect malfunctions. The examinations of the main and nose landing gears and actuators indicated thnt the gear was down and locked at impact. The left and right stabilizer jackscrews were recovered and the distance between the upper surfaces of the jackscrews' drive nuts and the lower surfaces of the actuators' upper stops was measured. These measurements indicated that the stabilizer was positioned at 5.71'aircraft noseup: Examination of the hydraulic system components did not reveal any evidence of internal operating distress. Thc control valvc of the 2-1 nonreversible motor pump was in the open position, indicating that the No. 2 hydraulic system was driving the No. 1 hydraulic system's pump. All eight flap actuators were recovered, and.investigators attempted to verify the position of the trailing edge flaps by measurin'ethe extension of the flap actuator pistons. The piston extensions were compared to those of another aircraft with flaps extended to 10'. Based on this comparison, some degree of B
15 -11- flap extension was probable, but the actual position could not be established. However, the DFDR data showed that the flaps were set at 109 A 3-ft section of the left wing's leading edge, just forward of the point where the forward part of the pylon joined the wing, whs torn away when the engine pylon assembly separated from the aircraft. The No. 1 and No. 3 hydraulic system's extension and retraction lines and the followup cables for the left wing's outboard slat drive actuators were severed. Thirty-five of the 36 leading edge slat tracks were examined. The examination disclosed that at impact the left wing's outboard slats were retracted, while the left wing's inboard slats and the right wing's inboard and outboard slats were extended to the takeoff position. The examination of the cockpit instruments did not disclose any usable informa'.ion Medical and Pathological Information A review of the autopsies and toxicological examinations of the fl,ghtcrew disclosed no ev~idence of preexisting physiological prpblemswhich could have affected their performance Fire The aircraft was subjected to severe ground fire Survival Aspects This accident w8s no? surviveble bcceusc impact forces exceeded human tolerances Tests and Research Study of Photographs FiOe'motographs taken of Flight 191's departure by two cameras--one in the terminal and one onboard a DC-10 on final approach to runway 9R-were sent to Lockheed's Palo Alto Research Laboratories for a Photo-Image Enhancement Study to determine the position of the flight controls. The process produced black and white images containing expanded variations of gray shading which, in the absence of the enhnncement process, would be too subtle for the eye to distinguish. Based on the study of 'these photo-images, the following observations were made: (1) The tail assembly was not damage& (2) the nose gear was down during the initial climbout and before the onset of roll; (3) spoilers Nos. I, 3, and 5 were extended on the right wing; and (41 the trailing edge of the right wing inboard aileron was up. Although the position cf the slats was difficult to determine, the left wing inboard slats appeared to be extended, and'the position of all other control surfaces appenred to be thc snme as recorded by the DFDR. The pitch and roll attitudes of the aircraft were extrapolated from the photographs, and extrapolations agreed closely with those recorded by the DFDR.
16 NlIOAA's pylon aft bulkhead was examined at the Safety Ijoard's 1 - : in the inbotra-oulo- 3.; ne Iraeture characteristi lond separation. Chevron and tear marks Qn the fracture indicated thnt lh~ ruplure progressed downward at the center of the flange, then in inbourd tmd oulbonrd directions on the flange. The bottom portion of the fracture exhibilcd snlwril~g consistcnt with the compression portion of a bending fracture. The sinrar WIIS IIIOW prevnlcnt-about 6 inches long-in the thinner center portion of llw upper I'langv struclurc, but became less prevalent at the outer ends of the. to he rcl;llivcly frci. of oxidation and dirt. z Fntiguc mt&ing was evident a* hth.iendl of tha.,traeture: At the ~nhn~~rd (!IN:. 11~' ifil!gw progressed inboard trnd aft; then, it progressed downward md 1nbomi 10 lhc tt;)orr inboard fustener that attached the forward section of the hulkl~okil lo llw r~ll srction. 'The fatigue progressed past the fastener R short dis111:1w bclorc r,stiibiting rnpid overstress characteristics in the downward d!rrelloll niil proccrdrd illong the inboerd side of the side flange radius of the forwnrd fl:mgc sivlton. A1 (he outboard end of the fracture, the fatigue propr~p~lcd io?i%:~rcl I I I I ~ sllghtly outboard toward the mmt forward outboard hole in lhc upper ~I~IEICV. 'I!w tot111 lcngtli of the overstress fracture and fatigue cracks was 111m1l 13 IIICI~CS. I'lw remuindcr of the fractures on the bulkhead und within lhc pylon 5lrurlurv rvwlted from ovcrload. ' 1 I IIC cs:~:~~inntion nlso discloscd that three shims were instalkd on the uppcr surfarc of llir I'orward upper flange. Two shims (Part No. AUB ) were m~t:illml, onc of! the inboard top shoulder of the upper flange and one on the ou'ttward lop sho~~idcr. lhcse shims are about 2 inches long, 1 inch wide, and.06j inch thick. A Ill-iwli-long..OSO-inch-thick shim was installed during production to fill :I p p bctwwn lhc upper flnngc and upper spar web. (See figure 6.) The ni~~~~uf,~rlurc.r's (iruw!nm specify that the AUB shim may be required dong the side 01 1Iw b.llkllcnrl: however, they do not indicate that shims may be required on Ihc uppcr surf:trr of the flange. 'The fatigue propagation on the inboard and outlmard cntk 01 t!w ovcrslress fracture began in the aiea underneath We.tlti3-lncll-tl~l<.k\111111<;. Thr ~ f fr~~crt~rc-st~rface t of thc upper flange contained a crescentr'orrmuon Wnch ~n~lohed tbe.shape of the lower end of the wing ctesis. nintton WHS in line '.with the vetiant, centeetina of the..af.t.. t)mcheud d-nlenf hole ws tndicnted by MNOW "d*' in figure?. A deformation WLS noted in the lowcr surfnre of the 1111 wing support fitting's forward clevis lug in the area atcd by tllc hr;rrkct.; 111 ftg skalbw gage was sppht in tlce :A?he tlrro+\: in :!.gure 10, s in a position which w& EORcQFm ',&#&.&$ne,,+lm&n. On-'t sf9alnblv. o f the..u- twwam&k*
18 Figure 5. View of the aft bulkhead pieceindicated as Item 1 in Figure 4.
20 ~~ Figure 7. Closer vi& of fracture on. upper flange in the Fig1 ire 8. Detail of deformation denoted by arrows "d" in Figu~ re 5 and 7.
PURPOSE Louisiana Tech University Flight Operations Cessna 172 VFR Profiles The information contained herein has been developed for the purpose of compliance with 14 CFR 141.85. The main objective of this
Flight Operations Briefing Notes I Introduction A tailstrike occurs if the tail of an aircraft touches the runway during takeoff or landing. It can occur with any type of aircraft although long aircraft
AVIATION INVESTIGATION REPORT A06O0104 IN-FLIGHT SEPARATION OF FLAP TAB EXPRESS NET AIRLINES AIRBUS A300 B4-203 N372PC TORONTO, ONTARIO 01 MAY 2006 The Transportation Safety Board of Canada (TSB) investigated
ENGINE FIRE / SEVERE DAMAGE / SEPARATION ON TAKEOFF According to RYANAIR Procedures PF PM REMARKS Control the aircraft (FULL T/O thrust can be manually selected) Announce «ENGINE FAILURE» or «ENGINE FIRE»
AVIATION INVESTIGATION REPORT A03P0068 SPIRAL DIVE - COLLISION WITH TERRAIN LANGLEY FLYING SCHOOL PIPER PA-28-140 C-GNUD LANGLEY AIRPORT, BRITISH COLUMBIA, 6 NM NE 25 MARCH 2003 The Transportation Safety
Cessna 172SP & NAV III Maneuvers Checklist Introduction Power Settings This document is intended to introduce to you the standard method of performing maneuvers in Sunair Aviation s Cessna 172SP and NAV
The Pilot s Manual 1: Flight School Aviation Supplies & Academics, Inc. 7005 132nd Place SE Newcastle, Washington 98059-3153 www.asa2fly.com Originally published by Aviation Theory Centre 1990 1993. Fourth
APPENDIX 3-B Airplane Upset Recovery Briefing Industry Solutions for Large Swept-Wing Turbofan Airplanes Typically Seating More Than 100 Passengers Briefing Figure 3-B.1 Revision 1_August 2004 Airplane
Location/Time Most Critical Injury: Investigated By: NTSB Nearest City/Place Zip Code Local Time Time Zone Orange MA 01364 2115 EDT Aircraft Information Registration Number Aircraft Manufacturer Model/Series
ASYMMETRIC FLIGHT INTRODUCTION This section provides a discussion of the asymmetric flight of multi-engine airplanes following loss of power from an engine(s) mounted laterally either side of the centerline.
Information regarding the Lockheed F-104 Starfighter F-104 Flight Controls An article published in the Zipper Magazine #46 June-2001 Author: Country: Website: Email: Theo N.M.M. Stoelinga The Netherlands
The Four Fundamental Flight Maneuvers: by: Darryl Kalthof www.bayareaflyinglessons.com c2010 Note you will get even more out of this file if you read a chapter on aerodynamics first! Elements: Effect and
Multiengine: Engine-Inoperative Principles 1/8 Multiengine: engine-inoperative principles Side slip vs. zero side slip With a multiengine airplane with all its engines operating, sideslip is eliminated
National Transportation Safety Board Washington, D.C. 20594 Safety Recommendation Honorable Donald D. Engen Administrator Federal Aviation Administration Washington, D.C. 20594 Date: March 4, 198G In reply
National Transportation Safety Board Washington, DC 20594 Brief of Incident Adopted 05/08/2001 IAD00IA032 File No. 684 03/30/2000 NEW YORK CITY, NY Aircraft Reg No. N182DN Time (Local): 20:25 EST Make/Model:
WINGS FLAP OPERATING LIMITATIONS 1. PLANNING INFORMATION A. Effectivity (1) Aircraft affected: N22 Series line sequence numbers 1 to 9, 11 to 29, 31, 33, 35, 37, 39 to 41, 43, 45, 47 to 59, 63, 65 to 70,
Automation at Odds The pilots of a Boeing 737-800 did not heed indications of a significant decrease in airspeed until the stick shaker activated on final approach to Runway 18R at Amsterdam (Netherlands)
MODULE 11B. PISTON AEROPLANE AERODYNAMICS, STRUCTURES AND SYSTEMS Note: The scope of this Module should reflect the technology of aeroplanes pertinent to the A2 and B1.2 subcategory. 11.1 Theory of Flight
This file contains the full script of the corresponding video, published on YouTube. November 2014: http://youtu.be/wbu6x0hsnby Background papers and links to formal FAA and EASA Aviation Regulations and
FLIGHT PERFORMANCE AND PLANNING PRIVATE PILOT LICENCE AEROPLANE MANUAL SACAA-01 FOR EXAMINATION PURPOSES ONLY PLEASE DO NOT MARK ON OR DAMAGE THIS MANUAL IN ANY WAY OCTOBER 2008 SOUTH AFRICAN CIVIL AVIATION
Flap system failure leading to loss of control involving Cessna 208, VH-WZJ Townsville Airport, Queensland,10 November 2015 ATSB Transport Safety Report Aviation Occurrence Investigation AO-2015-133 Final
Fan cowling separation resulting in horizontal stabilizer damage, Airbus A32-232, June 2, 2 Micro-summary: On rotation, the # fan cowling separated resulting in horizontal stabilizer damage to this A32.
TRAILING EDGE FLAP ASYMMETRY What is a trailing edge flap asymmetry? Condition: an uncommanded roll occurs when a new flap selection is made and/or difference between the left and right flap indication
Light Sport West Standard Flight Training Procedures for N110GX (Remos GX, 100 H.P.) Welcome to Light Sport West! Thank you for giving us the opportunity to provide all of your flight training needs. Our
Location/Time Aircraft Registration Number: Most Critical Injury: Fatal Investigated By: NTSB N57672 Nearest City/Place State Zip Code Local Time Time Zone Collinsville OK 74021 1800 CDT Airport Proximity:
Chief Inspector of Accidents Accident Investigation Division Civil Aviation Department 46 th Floor Queensway Government Offices 66 Queensway Hong Kong Accident Bulletin 1/2010 Aircraft type: Airbus A330-342
Effect of Propeller on Airplane Dynamics The propeller creates considerable unfavorable forces that need to be trimmed out to keep the airplane flying in a desirable manner. Many airplanes are rigged to
Flight Controls Controls and and Indicators 9.10 Flight Controls-Controls and Indicators Flight Control Panel (before Rudder System Enhancement Program (RSEP) modification) STBY RUD FLT CONTROL A B STBY
Smartcockpit.com BOEING 737 SYSTEMS REVIEW Page 1 FLIGHT CONTROLS 1. GENERAL The primary flight controls, ailerons, elevators and rudders, are hydraulically powered. Hydraulic power is provided from hydraulic
AVIATION OCCURRENCE REPORT REJECTED LANDING/LOSS OF CONTROL FIRST AIR DHC-6 SERIES 300 C-GNDN IQALUIT, NORTHWEST TERRITORIES 85 NM NW 12 AUGUST 1996 REPORT NUMBER A96Q0126 The Transportation Safety Board
US Sport Aircraft, Inc. SportCruiser Standard Operating Procedures and Maneuvers Supplement 1 1 This Supplement is not a replacement for personal Flight Instruction and shall only be used in conjunction
NATIONAL TRANSPORTATION SAFETY EOARD WASH IN GTO N, D. C. ISSUED: November 17. 1978 Honorable Langhorne M. Bond Admini strator Federal Aviation Administration Washington, D. C. 20591 -----------------_--
Engineers at Liftech designed the structure of the first container crane and have designed and reviewed thousands of container cranes since. Liftech is the structural review engineer of record for most
AMC Civil Aviation Authority The Netherlands Assessment Specifications for Remotely Piloted Aircraft Systems, Class 1 AS-RPAS1 Version 1.1 1 December 2014-1 - CONTENTS (general layout) AS RPAS1 REMOTELY
European Aviation Safety Agency Certification Specifications for Large Rotorcraft CS-29 11 December 2012 CS-29 CONTENTS (general layout) CS 29 LARGE ROTORCRAFT BOOK 1 CERTIFICATION SPECIFICATIONS SUBPART
AVIATION INVESTIGATION REPORT A06F0014 MISALIGNED TAKE-OFF AIR CANADA AIRBUS A319-114 C-FYKR LAS VEGAS, NEVADA 30 JANUARY 2006 The Transportation Safety Board of Canada (TSB) investigated this occurrence
PDQ 0/700 FESTOON SYSTEM INSTALLATION AND MAINTENANCE INSTRUCTIONS INTRODUCTION The PDQ Festoon System was designed to run on one of three sizes of I-beams: S x., S8 x 8. and S x.. System trolleys must
Titan Tornado AIRCRAFT CHECKLIST WARNING This manual is intended as a guide. It must be understood that all performance specifications will vary depending on the particular aircraft and load conditions.
FY05 Forest Service Aviation Accident Review In Memory of: Charles Edgar John Greeno José Gonzales National Aviation Safety Center Introduction Information Sharing NTSB regulation 831.13 Flow and dissemination
Accident Analysis: Single-pilot versus Two-pilot - Is There a Safety Advantage? AIN analysis comparing accidents involving one-pilot versus two-pilot business jet operations from 1977 through 2014 reveals,
Aircraft Registration Number: N8098T Occurrence Date: Occurrence Type: 03/07/005 Accident Most Critical Injury: Minor Investigated By: NTSB Location/Time Nearest City/Place Shreveport Zip Code Local Time
Ch 13.qxd 5/7/04 10:04 AM Page 13-1 TAILWHEEL AIRPLANES Tailwheel airplanes are often referred to as conventional gear airplanes. Due to their design and structure, tailwheel airplanes exhibit operational
Oral Preparation Questions The oral section of the practical test is the time when you need to demonstrate your understanding of the various tasks listed in the practical test standards and the factors
Note: The graphics and some of the material in this document have been modified from the original printed version. Introduction The major difference between flying a light twin and a single-engine airplane
Aerospace Engineering 3521: Flight Dynamics Prof. Eric Feron Homework 6 due October 20, 2014 1 Problem 1: Lateral-directional stability of Navion With the help of Chapter 2 of Nelson s textbook, we established
2100 AD 015 0009 Mirror Elevator Ball Nut Replacement Procedure Derek Guenther 1/28/2015 Rev. Purpose The purpose of this document is to describe the procedure necessary to replace one of the ball nuts
Lab 8 Notes Basic Aircraft Design Rules 6 Apr 06 Nomenclature x, y longitudinal, spanwise positions S reference area (wing area) b wing span c average wing chord ( = S/b ) AR wing aspect ratio C L lift
Air Accident Investigation Sector Accident - Preliminary Report - AAIS Case File N o : AIFN/0009/2015 Serious Injury to a Cabin Crewmember Due to Turbulence Operator: Emirates Make and Model: Airbus A380-800
CENTRAL TEXAS COLLEGE AIR AGENCY No DU8SO99Q SYLLABUS FOR AIRP 2342 FLIGHT INSTRUCTOR - INSTRUMENT AIRPLANE Semester Hours Credit: 3 CHIEF FLIGHT INSTRUCTOR - Richard E. Whitesell 2101 Carnation Ln Temple,
AVIATION INVESTIGATION REPORT A05W0160 LOSS OF CONTROL LANCAIR IV-P N750F SUNDRE, ALBERTA 8 NM SE 09 AUGUST 2005 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose
FAA APPROVED ROTORCRAFT FLIGHT MANUAL SUPPLEMENT STC SR01165SE Onboard Systems Cargo Hook Sling Suspension System Airbus Helicopters AS350 Series R/N S/N 1 of 15 Revision 1 Record of Revisions Rev. Date
Chapter 2 Basic Airplane Anatomy Objectives Identify components of basic aircraft anatomy Understand aircraft size and weight categories List different types and examples of General aviation aircraft Military
MANUAL REVERSION Manual reversion means that both hydraulic systems A & B are inoperative: the ailerons and elevator are controlled manually. A noticeable dead band will be observed in both of these controls
OWNER S MANUAL Model MH1230 Important Safety Instructions Assembly Instructions Parts and Hardware Identification Pallet Jack CAUTION: Read, understand and follow ALL instructions before using this product
Flight Controls The Wright Brothers were engineers first, pilots second. Introduction We have learned about the four forces that act on an airplane. The Wright Brothers were the first to fly because they
w Technical Product Information Subminiature Load Cell 1. Introduction... 2 2. Preparing for use... 2 2.1 Unpacking... 2 2.2 Using the instrument for the first time... 2 2.3 Grounding and potential connection...
Illustration 3c Control Y by D. Bruckert & O. Roud 2006 29 Trim System The Cessna 172 aircraft has a manually operated rudder and elevator trim system. Illustration 3d Trim tab Travel One trim tab is provided
SPACE INSTITUTE VARIABLE STABILITY FLIGHT OPERATIONS MANUAL Prepared by the Aviation Systems and Flight Research Department September 2004 Index 1.1 General Description...1 1.2 Variable Stability System...5
Principles of Flight There are four major forces acting on an aircraft: Gravity Lift Drag Thrust Gravity Gravity is the downward force that keeps the airplane on the ground or pulls the airplane toward
MT DIREION DE PERSONL ERONUTIO DPTO. DE INSTRUION PREGUNTS Y OPIONES POR TEM Pag.: 1 TEM: 0114 TP - (HP. 03) ERODYNMIS OD_PREG: PREGUNT: RPT: 8324 When are inboard ailerons normally used? OPION : Low-speed
Second interim Report A-008/2011 Accident involving a Bell 407 helicopter, registration EC-KTA, operated by Inaer, in Villastar (Teruel) on 19 March 2011 GOBIERNO DE ESPAÑA MINISTERIO DE FOMENTO Second
This is the third of a series of Atlantic Sun Airways CAT B pilot procedures and checklists for our fleet. Use them with good judgment. Dimensions: Span 107 ft 10 in Length 147 ft 10 in Height 29ft 7 in
FINAL INVESTIGATION REPORT Loss of Altitude during cruise of M/s Jet Airways B777-300ER aircraft VT-JEL on 08.08.2014 1. Aircraft Type : Boeing Model : B777-300ER Nationality : Indian Registration : VT-JEL
This is the third of a series of Atlantic Sun Airways CAT C pilot procedures and checklists for our fleet. Use them with good judgment. Note, the start procedures may vary from FS9 Panel to Panel. However
w Technical Product Information Precision Miniature Load Cell with Overload Protection 1. Introduction The load cells in the model 8431 and 8432 series are primarily designed for the measurement of force
MEMBER INSTALLATION INSTRUCTIONS AND OWNERS MANUAL Part # IS-SH5094, Rev 3, 04/204 www.seastarsolutions.com SH5294 DUAL SH5094 SINGLE jbs nfb Mechanical Steering for Inboard, Outboard, and Sterndrive Powered
Chapter 6 Lateral static stability and control - 3 Lecture 21 Topics 6.11 General discussions on control surface 6.11.1 Aerodynamic balancing 6.11.2 Set back hinge or over hang balance 6.11.3 Horn balanace
INSTALLATION INSTRUCTIONS WARNING: NEVER EXCEED YOUR VEHICLE MANUFACTURER'S RECOMMENDED TOWING CAPACITY 20 5TH WHEEL LEGS 25 5TH WHEEL LEGS 82214742 82214743 PARTS LIST Item# Qty Description 1 1 Passenger
Location/Time Aircraft Registration Number: Most Critical Injury: Minor Investigated By: NTSB N911BL Nearest /Place Zip Code Local Time Time Zone Las Vegas NV 89032 1600 PDT Airport Proximity: On Airport/Airstrip
Field Application Note Reverse Dial Indicator Alignment RDIA Mis-alignment can be the most usual cause for unacceptable operation and high vibration levels. New facilities or new equipment installations
The Purpose and Function of Airplane Parts Warm-Up Questions CPS Questions 1-2 Lesson Overview How the fuselage and wing shape correspond to an aircraft s mission The types, purpose, and function of airfoil
ACCIDENT Aircraft Type and Registration: No & Type of Engines: PA 31 Navajo, N80HF 2 Lycoming TIO-540-A2C piston engines Year of Manufacture: 1971 Date & Time (UTC): Location: Type of Flight: 25 July 2010
Revision 1.2 1 Revision 1.2 2 Manual for the Silent R 1,61m V2 Automatic-variable-pitch propeller V2 2-Blade suitable for Jabiru 2200. Edited: 08/06/07 This propeller is designed for experimental and ultralight
Pilot in Command The owner/operator is responsible for maintaining the aircraft in airworthy condition. The pilot in command is responsible for determining that the aircraft is safe and legal for flight.
Your consent to our cookies if you continue to use this website.