37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 144473 |
Time | |
Date | 199004 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ogg |
State Reference | HI |
Altitude | agl bound lower : 0 agl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ogg tower : ogg |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport |
Flight Phase | descent : approach descent other landing other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 9000 flight time type : 5000 |
ASRS Report | 144473 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 5800 flight time type : 1800 |
ASRS Report | 144587 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
The incident was a long landing (perhaps 1000-1500' past the aiming marks) at a speed of 5-10 KTS above vref with a vref of 129 KTS and reported calm wind. The first link in the chain of events was probably a descent clearance to 9000' at the place where we are 'always' cleared to 5000'. The captain noted that the altitude was high for the distance from the field. The captain noticed that they were still high, but that the first officer was aware and working on it. The captain reset the altitude alerter at the stepdown fix and looked for field again. With the field in sight, and the aircraft high, the first officer maintained a high rate of descent for a while, and then raised the nose a bit to lose speed in order to take more flaps. Shortly thereafter the aircraft slowed to maximum speed for the approach flap setting. First officer called for approach flaps and they were set. The captain then thought that there would be no problem getting down. However, the first officer lowered nose to lose altitude and when he called for landing flaps, the speed was 10 KTS too high. This was pointed out by the captain. When the speed was within limits for landing flaps, they were set. By that time, the captain was considering a probable go around, but he wanted the first officer to recognize the problem and initiate the go around. As the aircraft approached the threshold, the captain decided to command a go around, but as he glanced at the INS, he was extremely surprised to see a large decrease in airspeed since the last check. The EPR gauges showed the reason. The first officer had pulled off all power (unspooled both engines) the captain was completely surprised and instantly thought, 'unspooled--committed to land.' the captain expected about a 1500' T/D. It was probably 2000-2500' from the threshold due to a probable loss of tailwind and decreases in the rate of IAS loss. But as the nose gear touched down, and the first officer applied reverse thrust, the captain felt less than appropriate deceleration for the situation. The captain instructed the first officer to use full or maximum reverse (meaning the normal limit which is almost never used for passenger comfort and FOD reasons). The first officer said, 'help me.' the captain got on the brakes and found that he could do no better than the first officer. Now that remaining on the runway surface seemed out of the question, the captain thought he felt what he hoped were a few antiskid 'nibbles.' however, because of the poor braking action, he also thought that all tires may have been blown, and that what he felt might have been disintegrating tires, or compressor stalls. As the aircraft rolled to almost a dead stop on the centerline west/O leaving the runway, the captain decided to clear the runway. With the reversers stowed and brakes released, the ride at a slow walking speed was smooth; so, the captain turned off of the runway and stopped on the intersecting taxiway to evaluate the situation. Emergency equipment had been requested before stopping, and was on the way. A visibility inspection of both main gear areas indicated no damage other than flat inboard tires. In addition to all the human factors that were less than perfect, the antiskid failed and caused the inboard brakes to lock up at some point west/O having done any braking prior to that point. The inboard brake stacks (rotors and stators) were cold when the wheels were removed to replace the flat tires which had both been scrubbed off identically. The antiskid tested good prior to departure, showed no failure light en route, and tested good again on the ground as we sat there with flat inboards. The captain allowed his confidence in the first officer to lull him into a false sense of security concerning the 'unspooling' of the engines. The point of this rambling paragraph is that a very safety conscious pilot who had been in similar situations before, did not respond in the manner he would have expected himself to, and had done in the past. I couldn't believe that I had let the first officer unspool the engines and then didn't see it immediately and spool back up again. This item may or may not have contributed to the way in which I conducted myself. A few days before this incident, I had been informed by my sister than her 3 yr old son may have the worst type of agroup of diseases known by their symptoms as muscular dystrophy. A good cry with my sister a couple of days ago when the more accurate test showed a much worse # for the type of muscular dystrophy suspected may indicate that I only thought I wasn't let this bother my work. Supplemental information from acn 144587: en route to a familiar airport, ATIS reported WX better than 5000 and 5, calm wind and expect visibility approach. Seemed simple enough. Approach control assigned vectors for the NDB approach (very rarely used) and not the visibility! Only this and 1 other aircraft in our fleet have no leading edge slats which make slowing and configuring easier. To increase the margin of safety in such a case, I suggest the following: 1) better and more timely information from ATIS and ATC. 2) slowing the pace of events during an approach in demanding conditions even if this requires requesting wide vectors, missed approach or go around. 3) a more reliable anti-skid system.
Original NASA ASRS Text
Title: ACR MLG BLOWS TIRES ON LNDG.
Narrative: THE INCIDENT WAS A LONG LNDG (PERHAPS 1000-1500' PAST THE AIMING MARKS) AT A SPD OF 5-10 KTS ABOVE VREF WITH A VREF OF 129 KTS AND RPTED CALM WIND. THE FIRST LINK IN THE CHAIN OF EVENTS WAS PROBABLY A DSNT CLRNC TO 9000' AT THE PLACE WHERE WE ARE 'ALWAYS' CLRED TO 5000'. THE CAPT NOTED THAT THE ALT WAS HIGH FOR THE DISTANCE FROM THE FIELD. THE CAPT NOTICED THAT THEY WERE STILL HIGH, BUT THAT THE F/O WAS AWARE AND WORKING ON IT. THE CAPT RESET THE ALT ALERTER AT THE STEPDOWN FIX AND LOOKED FOR FIELD AGAIN. WITH THE FIELD IN SIGHT, AND THE ACFT HIGH, THE F/O MAINTAINED A HIGH RATE OF DSNT FOR A WHILE, AND THEN RAISED THE NOSE A BIT TO LOSE SPD IN ORDER TO TAKE MORE FLAPS. SHORTLY THEREAFTER THE ACFT SLOWED TO MAX SPD FOR THE APCH FLAP SETTING. F/O CALLED FOR APCH FLAPS AND THEY WERE SET. THE CAPT THEN THOUGHT THAT THERE WOULD BE NO PROB GETTING DOWN. HOWEVER, THE F/O LOWERED NOSE TO LOSE ALT AND WHEN HE CALLED FOR LNDG FLAPS, THE SPD WAS 10 KTS TOO HIGH. THIS WAS POINTED OUT BY THE CAPT. WHEN THE SPD WAS WITHIN LIMITS FOR LNDG FLAPS, THEY WERE SET. BY THAT TIME, THE CAPT WAS CONSIDERING A PROBABLE GO AROUND, BUT HE WANTED THE F/O TO RECOGNIZE THE PROB AND INITIATE THE GAR. AS THE ACFT APCHED THE THRESHOLD, THE CAPT DECIDED TO COMMAND A GAR, BUT AS HE GLANCED AT THE INS, HE WAS EXTREMELY SURPRISED TO SEE A LARGE DECREASE IN AIRSPD SINCE THE LAST CHK. THE EPR GAUGES SHOWED THE REASON. THE F/O HAD PULLED OFF ALL PWR (UNSPOOLED BOTH ENGS) THE CAPT WAS COMPLETELY SURPRISED AND INSTANTLY THOUGHT, 'UNSPOOLED--COMMITTED TO LAND.' THE CAPT EXPECTED ABOUT A 1500' T/D. IT WAS PROBABLY 2000-2500' FROM THE THRESHOLD DUE TO A PROBABLE LOSS OF TAILWIND AND DECREASES IN THE RATE OF IAS LOSS. BUT AS THE NOSE GEAR TOUCHED DOWN, AND THE F/O APPLIED REVERSE THRUST, THE CAPT FELT LESS THAN APPROPRIATE DECELERATION FOR THE SITUATION. THE CAPT INSTRUCTED THE F/O TO USE FULL OR MAX REVERSE (MEANING THE NORMAL LIMIT WHICH IS ALMOST NEVER USED FOR PAX COMFORT AND FOD REASONS). THE F/O SAID, 'HELP ME.' THE CAPT GOT ON THE BRAKES AND FOUND THAT HE COULD DO NO BETTER THAN THE F/O. NOW THAT REMAINING ON THE RWY SURFACE SEEMED OUT OF THE QUESTION, THE CAPT THOUGHT HE FELT WHAT HE HOPED WERE A FEW ANTISKID 'NIBBLES.' HOWEVER, BECAUSE OF THE POOR BRAKING ACTION, HE ALSO THOUGHT THAT ALL TIRES MAY HAVE BEEN BLOWN, AND THAT WHAT HE FELT MIGHT HAVE BEEN DISINTEGRATING TIRES, OR COMPRESSOR STALLS. AS THE ACFT ROLLED TO ALMOST A DEAD STOP ON THE CENTERLINE W/O LEAVING THE RWY, THE CAPT DECIDED TO CLR THE RWY. WITH THE REVERSERS STOWED AND BRAKES RELEASED, THE RIDE AT A SLOW WALKING SPD WAS SMOOTH; SO, THE CAPT TURNED OFF OF THE RWY AND STOPPED ON THE INTERSECTING TXWY TO EVALUATE THE SITUATION. EMER EQUIP HAD BEEN REQUESTED BEFORE STOPPING, AND WAS ON THE WAY. A VIS INSPECTION OF BOTH MAIN GEAR AREAS INDICATED NO DAMAGE OTHER THAN FLAT INBOARD TIRES. IN ADDITION TO ALL THE HUMAN FACTORS THAT WERE LESS THAN PERFECT, THE ANTISKID FAILED AND CAUSED THE INBOARD BRAKES TO LOCK UP AT SOME POINT W/O HAVING DONE ANY BRAKING PRIOR TO THAT POINT. THE INBOARD BRAKE STACKS (ROTORS AND STATORS) WERE COLD WHEN THE WHEELS WERE REMOVED TO REPLACE THE FLAT TIRES WHICH HAD BOTH BEEN SCRUBBED OFF IDENTICALLY. THE ANTISKID TESTED GOOD PRIOR TO DEP, SHOWED NO FAILURE LIGHT ENRTE, AND TESTED GOOD AGAIN ON THE GND AS WE SAT THERE WITH FLAT INBOARDS. THE CAPT ALLOWED HIS CONFIDENCE IN THE F/O TO LULL HIM INTO A FALSE SENSE OF SECURITY CONCERNING THE 'UNSPOOLING' OF THE ENGS. THE POINT OF THIS RAMBLING PARAGRAPH IS THAT A VERY SAFETY CONSCIOUS PLT WHO HAD BEEN IN SIMILAR SITUATIONS BEFORE, DID NOT RESPOND IN THE MANNER HE WOULD HAVE EXPECTED HIMSELF TO, AND HAD DONE IN THE PAST. I COULDN'T BELIEVE THAT I HAD LET THE F/O UNSPOOL THE ENGS AND THEN DIDN'T SEE IT IMMEDIATELY AND SPOOL BACK UP AGAIN. THIS ITEM MAY OR MAY NOT HAVE CONTRIBUTED TO THE WAY IN WHICH I CONDUCTED MYSELF. A FEW DAYS BEFORE THIS INCIDENT, I HAD BEEN INFORMED BY MY SISTER THAN HER 3 YR OLD SON MAY HAVE THE WORST TYPE OF AGROUP OF DISEASES KNOWN BY THEIR SYMPTOMS AS MUSCULAR DYSTROPHY. A GOOD CRY WITH MY SISTER A COUPLE OF DAYS AGO WHEN THE MORE ACCURATE TEST SHOWED A MUCH WORSE # FOR THE TYPE OF MUSCULAR DYSTROPHY SUSPECTED MAY INDICATE THAT I ONLY THOUGHT I WASN'T LET THIS BOTHER MY WORK. SUPPLEMENTAL INFO FROM ACN 144587: ENRTE TO A FAMILIAR ARPT, ATIS RPTED WX BETTER THAN 5000 AND 5, CALM WIND AND EXPECT VIS APCH. SEEMED SIMPLE ENOUGH. APCH CTL ASSIGNED VECTORS FOR THE NDB APCH (VERY RARELY USED) AND NOT THE VIS! ONLY THIS AND 1 OTHER ACFT IN OUR FLEET HAVE NO LEADING EDGE SLATS WHICH MAKE SLOWING AND CONFIGURING EASIER. TO INCREASE THE MARGIN OF SAFETY IN SUCH A CASE, I SUGGEST THE FOLLOWING: 1) BETTER AND MORE TIMELY INFO FROM ATIS AND ATC. 2) SLOWING THE PACE OF EVENTS DURING AN APCH IN DEMANDING CONDITIONS EVEN IF THIS REQUIRES REQUESTING WIDE VECTORS, MISSED APCH OR GAR. 3) A MORE RELIABLE ANTI-SKID SYS.
Data retrieved from NASA's ASRS site as of July 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.