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Attributes | |
ACN | 107397 |
Time | |
Date | 198903 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : sjo |
State Reference | FO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 201 flight time total : 18800 flight time type : 5000 |
ASRS Report | 107397 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe conflict : ground less severe non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : overcame equipment problem none taken : unable |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
Excessive ground roll in costa rica due to problems listed on full report enclosed. Causing abrupt rotation to avoid collision with runway end lights at takeoff. Report on costa rica-miami flight, 3/tue/89: aircraft was loaded in accordance with air carrier a runway analysis for runway 7 at sjo. Takeoff weight was slightly less than the maximum allowed (278000). The fuel tanks were stuck by the flight engineer in sjo. At the end of the runway the stan system was checked and was reported to be averaging between 278000 and 276000. I set the parking brake. When the engines were reported at maximum thrust released the brakes and started the takeoff roll. All indications were normal up to and past V1 (136 KTS). Approaching vr (141 KTS) it became apparent to me that we would reach vr and the end of the runway simultaneously. A normal rotation would have put the main gear through the lights at the end of the runway and would have damaged the tires and undercarriage. There was also the possibility an impact with the lights and structures at the end of the runway would have resulted in forces which would have delayed the rotation to such an extent that at the weight and with the rising imminent terrain we could have been presented with a total loss of the aircraft and crew. Nothing short of an exact, immediate and aggressive rotation could save the aircraft. I rotated in this manner and the main gear cleared the runway lights. The aircraft was over them at the time of rotation. Upon landing in mia a captain from air carrier B came directly from his aircraft at gac and asked what happened in costa rica. Both crews were standing at the tail inspecting the aft underbelly where the skin was scraped due to contact with the runway in sjo. He said that the tower in sjo had remarked to him about the takeoff and he had stated that he had seen the takeoff roll and knew that we were in trouble. I called fl west general manager upon clearing customs, reported the incident to him and recommended that the 90083 pounds of cargo be re-weighed. This was accomplished and the lead mechanic reported later the weight came out to be 95552 pounds. The lead man felt there was a possibility there was 1200 pounds of unstickable fuel in the center tank (the center tank gauge was dmi'd). He also mentioned that we were carrying around a main wheel which was not manifested. These errors could have totaled 7119 pounds overweight if allowing 450 pounds for the wheel and tire. I returned to the aircraft approximately 1 1/2 hours after landing in mia to feel the brakes. All the rear brakes were still more than warm and all the front brakes were cold. (Note: although the brakes were checked prior to the next flight, on that next flight it was reported that the #2 front and rear were hot on landing in sjo.) I strongly feel there is a distinct possibility I was receiving incorrect information from the captain's horizon during rotation in sjo as this instrument failed in a 30 degree left bank shortly thereafter. We bootstrapped and wrote up the horizon on the way home (log page 7001). In summation, I would say that we experienced many things going wrong at the same time, none of which were within control of the flight crew. Listed below are some of the possibilities that I feel could have contributed to this incident: 1) dragging brakes, 2) incorrect reading on stan system, 3) incorrect weighing of cargo in sjo, 4) sluggish artificial horizon, 5) hidden fuel (center tank), 6) incorrect basic operating weight (not reported spares), 7) wind shear or loss of reported wind at sjo. Upon landing in mia the aircraft paid off early due to a wrong bug set due to the incorrect weight on board. I felt a boeing type landing with a drop of about 2 ft, however the deck angle prevented any contact with the tail. Corrective action: 1) inspection and certification of all scales used to weigh cargo in or out of the us. 2) time limits set on artificial horizons and other important instruments. 3) cockpit brake temperature indicators on all transport aircraft, 4) stan system checked at increased regular intervals. Callback conversation with reporter revealed the following: the reporter stated that the planned takeoff weight had required the application of weight increases gained by not using turbo compressors and by applying headwind corrections. However, this does not explain the unacceptable takeoff acceleration distance and is in fact quite routine. The reporter believes the flaps were set correctly and the brakes were probably not dragging, although it remains a possibility. The reporter now believes that the engines were for some reason not producing expected thrust and this is what caused the excessive takeoff run. It appears to analyst that no conclusive reason has yet been discovered.
Original NASA ASRS Text
Title: ACFT REQUIRED EXCESSIVE RWY DURING ACCELERATION TO TKOF SPEED. ABRUPT ROTATION TECHNIQUE RESULTED IN TAIL STRIKE. ACFT MAY HAVE BEEN OVERWEIGHT.
Narrative: EXCESSIVE GND ROLL IN COSTA RICA DUE TO PROBS LISTED ON FULL RPT ENCLOSED. CAUSING ABRUPT ROTATION TO AVOID COLLISION WITH RWY END LIGHTS AT TKOF. RPT ON COSTA RICA-MIAMI FLT, 3/TUE/89: ACFT WAS LOADED IN ACCORDANCE WITH ACR A RWY ANALYSIS FOR RWY 7 AT SJO. TKOF WT WAS SLIGHTLY LESS THAN THE MAX ALLOWED (278000). THE FUEL TANKS WERE STUCK BY THE FE IN SJO. AT THE END OF THE RWY THE STAN SYS WAS CHKED AND WAS RPTED TO BE AVERAGING BTWN 278000 AND 276000. I SET THE PARKING BRAKE. WHEN THE ENGS WERE RPTED AT MAX THRUST RELEASED THE BRAKES AND STARTED THE TKOF ROLL. ALL INDICATIONS WERE NORMAL UP TO AND PAST V1 (136 KTS). APCHING VR (141 KTS) IT BECAME APPARENT TO ME THAT WE WOULD REACH VR AND THE END OF THE RWY SIMULTANEOUSLY. A NORMAL ROTATION WOULD HAVE PUT THE MAIN GEAR THROUGH THE LIGHTS AT THE END OF THE RWY AND WOULD HAVE DAMAGED THE TIRES AND UNDERCARRIAGE. THERE WAS ALSO THE POSSIBILITY AN IMPACT WITH THE LIGHTS AND STRUCTURES AT THE END OF THE RWY WOULD HAVE RESULTED IN FORCES WHICH WOULD HAVE DELAYED THE ROTATION TO SUCH AN EXTENT THAT AT THE WT AND WITH THE RISING IMMINENT TERRAIN WE COULD HAVE BEEN PRESENTED WITH A TOTAL LOSS OF THE ACFT AND CREW. NOTHING SHORT OF AN EXACT, IMMEDIATE AND AGGRESSIVE ROTATION COULD SAVE THE ACFT. I ROTATED IN THIS MANNER AND THE MAIN GEAR CLRED THE RWY LIGHTS. THE ACFT WAS OVER THEM AT THE TIME OF ROTATION. UPON LNDG IN MIA A CAPT FROM ACR B CAME DIRECTLY FROM HIS ACFT AT GAC AND ASKED WHAT HAPPENED IN COSTA RICA. BOTH CREWS WERE STANDING AT THE TAIL INSPECTING THE AFT UNDERBELLY WHERE THE SKIN WAS SCRAPED DUE TO CONTACT WITH THE RWY IN SJO. HE SAID THAT THE TWR IN SJO HAD REMARKED TO HIM ABOUT THE TKOF AND HE HAD STATED THAT HE HAD SEEN THE TKOF ROLL AND KNEW THAT WE WERE IN TROUBLE. I CALLED FL W GENERAL MGR UPON CLEARING CUSTOMS, RPTED THE INCIDENT TO HIM AND RECOMMENDED THAT THE 90083 LBS OF CARGO BE RE-WEIGHED. THIS WAS ACCOMPLISHED AND THE LEAD MECH RPTED LATER THE WT CAME OUT TO BE 95552 LBS. THE LEAD MAN FELT THERE WAS A POSSIBILITY THERE WAS 1200 LBS OF UNSTICKABLE FUEL IN THE CENTER TANK (THE CENTER TANK GAUGE WAS DMI'D). HE ALSO MENTIONED THAT WE WERE CARRYING AROUND A MAIN WHEEL WHICH WAS NOT MANIFESTED. THESE ERRORS COULD HAVE TOTALED 7119 LBS OVERWEIGHT IF ALLOWING 450 LBS FOR THE WHEEL AND TIRE. I RETURNED TO THE ACFT APPROX 1 1/2 HRS AFTER LNDG IN MIA TO FEEL THE BRAKES. ALL THE REAR BRAKES WERE STILL MORE THAN WARM AND ALL THE FRONT BRAKES WERE COLD. (NOTE: ALTHOUGH THE BRAKES WERE CHKED PRIOR TO THE NEXT FLT, ON THAT NEXT FLT IT WAS RPTED THAT THE #2 FRONT AND REAR WERE HOT ON LNDG IN SJO.) I STRONGLY FEEL THERE IS A DISTINCT POSSIBILITY I WAS RECEIVING INCORRECT INFO FROM THE CAPT'S HORIZON DURING ROTATION IN SJO AS THIS INSTRUMENT FAILED IN A 30 DEG LEFT BANK SHORTLY THEREAFTER. WE BOOTSTRAPPED AND WROTE UP THE HORIZON ON THE WAY HOME (LOG PAGE 7001). IN SUMMATION, I WOULD SAY THAT WE EXPERIENCED MANY THINGS GOING WRONG AT THE SAME TIME, NONE OF WHICH WERE WITHIN CONTROL OF THE FLC. LISTED BELOW ARE SOME OF THE POSSIBILITIES THAT I FEEL COULD HAVE CONTRIBUTED TO THIS INCIDENT: 1) DRAGGING BRAKES, 2) INCORRECT READING ON STAN SYS, 3) INCORRECT WEIGHING OF CARGO IN SJO, 4) SLUGGISH ARTIFICIAL HORIZON, 5) HIDDEN FUEL (CENTER TANK), 6) INCORRECT BASIC OPERATING WT (NOT RPTED SPARES), 7) WIND SHEAR OR LOSS OF RPTED WIND AT SJO. UPON LNDG IN MIA THE ACFT PAID OFF EARLY DUE TO A WRONG BUG SET DUE TO THE INCORRECT WT ON BOARD. I FELT A BOEING TYPE LNDG WITH A DROP OF ABOUT 2 FT, HOWEVER THE DECK ANGLE PREVENTED ANY CONTACT WITH THE TAIL. CORRECTIVE ACTION: 1) INSPECTION AND CERTIFICATION OF ALL SCALES USED TO WEIGH CARGO IN OR OUT OF THE US. 2) TIME LIMITS SET ON ARTIFICIAL HORIZONS AND OTHER IMPORTANT INSTRUMENTS. 3) COCKPIT BRAKE TEMP INDICATORS ON ALL TRANSPORT ACFT, 4) STAN SYS CHKED AT INCREASED REGULAR INTERVALS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE RPTR STATED THAT THE PLANNED TKOF WT HAD REQUIRED THE APPLICATION OF WT INCREASES GAINED BY NOT USING TURBO COMPRESSORS AND BY APPLYING HEADWIND CORRECTIONS. HOWEVER, THIS DOES NOT EXPLAIN THE UNACCEPTABLE TKOF ACCELERATION DISTANCE AND IS IN FACT QUITE ROUTINE. THE RPTR BELIEVES THE FLAPS WERE SET CORRECTLY AND THE BRAKES WERE PROBABLY NOT DRAGGING, ALTHOUGH IT REMAINS A POSSIBILITY. THE RPTR NOW BELIEVES THAT THE ENGS WERE FOR SOME REASON NOT PRODUCING EXPECTED THRUST AND THIS IS WHAT CAUSED THE EXCESSIVE TKOF RUN. IT APPEARS TO ANALYST THAT NO CONCLUSIVE REASON HAS YET BEEN DISCOVERED.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.