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|
Attributes | |
ACN | 383954 |
Time | |
Date | 199710 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : str |
State Reference | FO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | L-1011 Tri-Star All Series |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : takeoff other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 6000 |
ASRS Report | 383954 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 20200 flight time type : 4000 |
ASRS Report | 383688 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : rejected takeoff other |
Consequence | other Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation other |
Narrative:
This narrative is a description of the events that took place on rotation that started on oct/mon/97. The flight was the return leg str-atl on oct/thu/97. The cockpit crew consisted of standard L1011 crew of 3. The captain was receiving a line check, so there was a line check airman on board. The following description is based on the events that took place on oct/thu/97, in str as observed or perceived by the first officer. The takeoff roll was accomplished using a maximum power, no packs, 18 degree flaps takeoff. V1 was 151 KTS, vr was approximately 160 KTS and V2 was approximately 171 KTS. Acceleration and cockpit instruments indications were normal and standard callouts were made. At approximately 145 KTS I started to feel a slight vibration, at 145-147 KTS a muffled explosion was felt followed by a stronger vibration. The aircraft yawed to the right followed by a slight roll to the right. The aircraft veered off centerline. The cockpit indications were a red vibration light illuminated on the pilot's annunciator panel. The captain initiated an abort and brought the aircraft back to centerline. I called the str tower and informed them that 'our air carrier is aborting at 145 KTS.' the captain did an excellent job of bringing the aircraft to a safe and complete stop at the end of the runway. The aircraft was taxied off the runway onto the holding point for runway 25. I looked at the captain for instructions, but he appeared busy taxiing the aircraft. I called str tower and asked them if they could see any flames or smoke. Str tower stated that they could not see any flames, but, we had smoke coming from our wheels. We then checked the engine instruments and noted that with the throttles at idle, the #3 egt reading was approximately 800 degrees and the thrust reversers had failed to stow. I looked at the captain and he did not say anything. I felt it prudent to request fire coverage from str tower. Tower dispatched the fire trucks. I looked at the captain again for direction, when I got none, I directed the lca and the flight attendant in charge to look for signs of fire. They both returned and indicated that there was no indications of flames or fire. The so suggested that we accomplish the engine fire/severe damage abnormal procedure for the #3 engine. The so and myself accomplished this checklist. The fire bottle was not fired due to absence of fire indications. At this time there was also a discussion between the so, the lca and myself about checking the brake energy limits charts. In the heat of the battle the so had difficulty finding the chart until the lca directed him to it. At this time, I also informed the captain that we needed to say something to the people in order to let them know what is going on. During this time there was a discussion about evacuate/evacuation and the evacuate/evacuation checklist was reviewed. The so was very concerned about the aircraft and had relayed information about our condition to str operations which in turn sent it to flight control. Flight control misinterpreted our condition and suggested that we evacuate/evacuation the aircraft. The so seemed to be leaning towards having an evacuate/evacuation. The lca and I felt an evacuate/evacuation was not warranted because we had no fire. We had fire trucks standing by, the potential for injury to the passenger in an evacuate/evacuation and the str operations had placed a high priority call to str airport for mobile stairs. During this time our maintenance people showed up and confirmed blown tires and damage to the #3 engine. There were no injuries to passenger or crew members. The passenger and crew deplaned normally through the mobile stairs and the cockpit crew was taken to str airport operations to talk to the german FAA representative. Supplemental information from acn 383688: the airplane was near maximum allowable takeoff weight when it became necessary to abort at 145-147 KTS due to #3 engine failure and what seemed like some blown tires. We were able to stop and clear the runway at the end before all the tires blew out. Fortunately no fire developed so the passenger remained onboard until portable stairs and 'mobile lounges' arrived. No one was injured. However, a close investigation might reveal a less than ideal situation. There was a check ride in progress by a very zealous company check airman. This individual insisted on following all procedures to the letter as in a simulator training environment without any adaptation to actual circumstances. This made flight planning long and tedious, and preflight preparations hurried and stressful as the corrections and instructions continued. Not surprisingly, some mistakes were made under these circumstances. I typed an erroneous present position into the FMS (with sticky keyboard). I feel that the INS warning system would bring this to my attention, or the yet-to-be run checklist, or one of the other crew members would catch this mistake. The check airman caught it first, so it was, of course, recorded on the voice recorder as a grave error. Shortly, the so left the flap setting off the takeoff reference card. The first officer set the flaps at the usual 14 degrees, but this takeoff was to use 18 degrees. The check airman declared 'we were about to kill someone.' this damning declaration is also on our voice recorder for the world to hear. The fact was that there was still a checklist to be run in which all 3 crew members check the flap setting. Furthermore 14 degrees was a usable setting for this takeoff. After the abort this individual was of some help (ie, visually observing the engine for fire) and some hindrance as he wanted to be sure things were done his way. The first and so's performed their functions as trained to do under the 'crew concept' excellently. I was criticized for not being more forceful in telling them to do what they were already doing. So we executed successfully high speed aborted takeoff, but not without some underlying human performance shortcomings.
Original NASA ASRS Text
Title: AN ACR L101 FLC REJECTED THEIR HVY WT TKOF BECAUSE OF ENG FAILURE. THE REJECT SPD WAS BELOW V1, BUT ALL OF THE MAIN GEAR TIRES FAILED FROM THE STRESS OF THE TKOF AND REJECT. THERE WERE NO INJURIES, HOWEVER THERE WERE A NUMBER OF HUMAN FACTORS ISSUES BTWN THE FLC MEMBERS AND WITH A LINE CHK AIRMAN IN THE FLT STATION.
Narrative: THIS NARRATIVE IS A DESCRIPTION OF THE EVENTS THAT TOOK PLACE ON ROTATION THAT STARTED ON OCT/MON/97. THE FLT WAS THE RETURN LEG STR-ATL ON OCT/THU/97. THE COCKPIT CREW CONSISTED OF STANDARD L1011 CREW OF 3. THE CAPT WAS RECEIVING A LINE CHK, SO THERE WAS A LINE CHK AIRMAN ON BOARD. THE FOLLOWING DESCRIPTION IS BASED ON THE EVENTS THAT TOOK PLACE ON OCT/THU/97, IN STR AS OBSERVED OR PERCEIVED BY THE FO. THE TKOF ROLL WAS ACCOMPLISHED USING A MAX PWR, NO PACKS, 18 DEG FLAPS TKOF. V1 WAS 151 KTS, VR WAS APPROX 160 KTS AND V2 WAS APPROX 171 KTS. ACCELERATION AND COCKPIT INSTS INDICATIONS WERE NORMAL AND STANDARD CALLOUTS WERE MADE. AT APPROX 145 KTS I STARTED TO FEEL A SLIGHT VIBRATION, AT 145-147 KTS A MUFFLED EXPLOSION WAS FELT FOLLOWED BY A STRONGER VIBRATION. THE ACFT YAWED TO THE R FOLLOWED BY A SLIGHT ROLL TO THE R. THE ACFT VEERED OFF CTRLINE. THE COCKPIT INDICATIONS WERE A RED VIBRATION LIGHT ILLUMINATED ON THE PLT'S ANNUNCIATOR PANEL. THE CAPT INITIATED AN ABORT AND BROUGHT THE ACFT BACK TO CTRLINE. I CALLED THE STR TWR AND INFORMED THEM THAT 'OUR ACR IS ABORTING AT 145 KTS.' THE CAPT DID AN EXCELLENT JOB OF BRINGING THE ACFT TO A SAFE AND COMPLETE STOP AT THE END OF THE RWY. THE ACFT WAS TAXIED OFF THE RWY ONTO THE HOLDING POINT FOR RWY 25. I LOOKED AT THE CAPT FOR INSTRUCTIONS, BUT HE APPEARED BUSY TAXIING THE ACFT. I CALLED STR TWR AND ASKED THEM IF THEY COULD SEE ANY FLAMES OR SMOKE. STR TWR STATED THAT THEY COULD NOT SEE ANY FLAMES, BUT, WE HAD SMOKE COMING FROM OUR WHEELS. WE THEN CHKED THE ENG INSTS AND NOTED THAT WITH THE THROTTLES AT IDLE, THE #3 EGT READING WAS APPROX 800 DEGS AND THE THRUST REVERSERS HAD FAILED TO STOW. I LOOKED AT THE CAPT AND HE DID NOT SAY ANYTHING. I FELT IT PRUDENT TO REQUEST FIRE COVERAGE FROM STR TWR. TWR DISPATCHED THE FIRE TRUCKS. I LOOKED AT THE CAPT AGAIN FOR DIRECTION, WHEN I GOT NONE, I DIRECTED THE LCA AND THE FLT ATTENDANT IN CHARGE TO LOOK FOR SIGNS OF FIRE. THEY BOTH RETURNED AND INDICATED THAT THERE WAS NO INDICATIONS OF FLAMES OR FIRE. THE SO SUGGESTED THAT WE ACCOMPLISH THE ENG FIRE/SEVERE DAMAGE ABNORMAL PROC FOR THE #3 ENG. THE SO AND MYSELF ACCOMPLISHED THIS CHKLIST. THE FIRE BOTTLE WAS NOT FIRED DUE TO ABSENCE OF FIRE INDICATIONS. AT THIS TIME THERE WAS ALSO A DISCUSSION BTWN THE SO, THE LCA AND MYSELF ABOUT CHKING THE BRAKE ENERGY LIMITS CHARTS. IN THE HEAT OF THE BATTLE THE SO HAD DIFFICULTY FINDING THE CHART UNTIL THE LCA DIRECTED HIM TO IT. AT THIS TIME, I ALSO INFORMED THE CAPT THAT WE NEEDED TO SAY SOMETHING TO THE PEOPLE IN ORDER TO LET THEM KNOW WHAT IS GOING ON. DURING THIS TIME THERE WAS A DISCUSSION ABOUT EVAC AND THE EVAC CHKLIST WAS REVIEWED. THE SO WAS VERY CONCERNED ABOUT THE ACFT AND HAD RELAYED INFO ABOUT OUR CONDITION TO STR OPS WHICH IN TURN SENT IT TO FLT CTL. FLT CTL MISINTERPRETED OUR CONDITION AND SUGGESTED THAT WE EVAC THE ACFT. THE SO SEEMED TO BE LEANING TOWARDS HAVING AN EVAC. THE LCA AND I FELT AN EVAC WAS NOT WARRANTED BECAUSE WE HAD NO FIRE. WE HAD FIRE TRUCKS STANDING BY, THE POTENTIAL FOR INJURY TO THE PAX IN AN EVAC AND THE STR OPS HAD PLACED A HIGH PRIORITY CALL TO STR ARPT FOR MOBILE STAIRS. DURING THIS TIME OUR MAINT PEOPLE SHOWED UP AND CONFIRMED BLOWN TIRES AND DAMAGE TO THE #3 ENG. THERE WERE NO INJURIES TO PAX OR CREW MEMBERS. THE PAX AND CREW DEPLANED NORMALLY THROUGH THE MOBILE STAIRS AND THE COCKPIT CREW WAS TAKEN TO STR ARPT OPS TO TALK TO THE GERMAN FAA REPRESENTATIVE. SUPPLEMENTAL INFO FROM ACN 383688: THE AIRPLANE WAS NEAR MAX ALLOWABLE TKOF WT WHEN IT BECAME NECESSARY TO ABORT AT 145-147 KTS DUE TO #3 ENG FAILURE AND WHAT SEEMED LIKE SOME BLOWN TIRES. WE WERE ABLE TO STOP AND CLR THE RWY AT THE END BEFORE ALL THE TIRES BLEW OUT. FORTUNATELY NO FIRE DEVELOPED SO THE PAX REMAINED ONBOARD UNTIL PORTABLE STAIRS AND 'MOBILE LOUNGES' ARRIVED. NO ONE WAS INJURED. HOWEVER, A CLOSE INVESTIGATION MIGHT REVEAL A LESS THAN IDEAL SIT. THERE WAS A CHK RIDE IN PROGRESS BY A VERY ZEALOUS COMPANY CHK AIRMAN. THIS INDIVIDUAL INSISTED ON FOLLOWING ALL PROCS TO THE LETTER AS IN A SIMULATOR TRAINING ENVIRONMENT WITHOUT ANY ADAPTATION TO ACTUAL CIRCUMSTANCES. THIS MADE FLT PLANNING LONG AND TEDIOUS, AND PREFLT PREPARATIONS HURRIED AND STRESSFUL AS THE CORRECTIONS AND INSTRUCTIONS CONTINUED. NOT SURPRISINGLY, SOME MISTAKES WERE MADE UNDER THESE CIRCUMSTANCES. I TYPED AN ERRONEOUS PRESENT POS INTO THE FMS (WITH STICKY KEYBOARD). I FEEL THAT THE INS WARNING SYS WOULD BRING THIS TO MY ATTN, OR THE YET-TO-BE RUN CHKLIST, OR ONE OF THE OTHER CREW MEMBERS WOULD CATCH THIS MISTAKE. THE CHK AIRMAN CAUGHT IT FIRST, SO IT WAS, OF COURSE, RECORDED ON THE VOICE RECORDER AS A GRAVE ERROR. SHORTLY, THE SO LEFT THE FLAP SETTING OFF THE TKOF REF CARD. THE FO SET THE FLAPS AT THE USUAL 14 DEGS, BUT THIS TKOF WAS TO USE 18 DEGS. THE CHK AIRMAN DECLARED 'WE WERE ABOUT TO KILL SOMEONE.' THIS DAMNING DECLARATION IS ALSO ON OUR VOICE RECORDER FOR THE WORLD TO HEAR. THE FACT WAS THAT THERE WAS STILL A CHKLIST TO BE RUN IN WHICH ALL 3 CREW MEMBERS CHK THE FLAP SETTING. FURTHERMORE 14 DEGS WAS A USABLE SETTING FOR THIS TKOF. AFTER THE ABORT THIS INDIVIDUAL WAS OF SOME HELP (IE, VISUALLY OBSERVING THE ENG FOR FIRE) AND SOME HINDRANCE AS HE WANTED TO BE SURE THINGS WERE DONE HIS WAY. THE FIRST AND SO'S PERFORMED THEIR FUNCTIONS AS TRAINED TO DO UNDER THE 'CREW CONCEPT' EXCELLENTLY. I WAS CRITICIZED FOR NOT BEING MORE FORCEFUL IN TELLING THEM TO DO WHAT THEY WERE ALREADY DOING. SO WE EXECUTED SUCCESSFULLY HIGH SPD ABORTED TKOF, BUT NOT WITHOUT SOME UNDERLYING HUMAN PERFORMANCE SHORTCOMINGS.
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.