37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 418794 |
Time | |
Date | 199811 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : atl airport : atl |
State Reference | GA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Flight Phase | landing other other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private |
Experience | flight time last 90 days : 175 flight time total : 18500 flight time type : 2500 |
ASRS Report | 418794 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 85 flight time total : 4976 flight time type : 168 |
ASRS Report | 418792 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : detected after the fact |
Consequence | other Other |
Supplementary | |
Primary Problem | Aircraft |
Narrative:
I arrived at the airplane about 50 mins before departure time, met the first officer and flight attendants, and then went to the ticket counter to obtain the dispatch release. Dispatch had left a message to call, and when I did, they informed me of an additional item to add to the release, which was that the #2 engine thrust reverser was inoperative. The release called for 31000 pounds of fuel, but I requested 29000 pounds, which was still well above the minimum. During the walkaround inspection, the first officer discovered that the hydraulic quantity was low. I requested that maintenance service the hydraulics, which they did, but a logbook entry to that effect was not made. The flight departed on time and everything was normal until climbing through FL180, when I noticed that the hydraulic quantity was low and was approaching zero. The 'a' hydraulic system low pressure lights came on and the 'a' hydraulic pressure dropped to zero. We advised ATC and requested a return to atl. I advised ATC that we needed a long straight-in approach and they advised that we were then turning onto a straight-in approach and they asked if we wanted runway 9L or runway 9R. We selected runway 9L, which was the longest runway at atl and picked up the runway visually at about 15 mi out. We were then cleared for a visual approach. I then declared an emergency and requested the emergency equipment. I then made another PA announcement to the passenger and advised them that emergency equipment would be responding but that it was just a precaution. We were slightly high on the approach, so I requested that the first officer extend the landing gear then, which was out of sequence, but I needed the additional drag to slow the airplane. He extended the gear using the emergency extension method. I then slowed to flap extension speed and he began to extend the flaps using the emergency method. Flaps were extending very slowly, which is normal using this method, but I was concerned that we would not reach 15 degrees (landing flaps) in time for a stabilized approach, so I requested a 360 degree turn, which tower could not approve at that time due to traffic. A short time later, the tower advised that they could move the other traffic and we could make the 360 degree turn. By that time the flaps were at 15 degrees, so I elected not to make the turn and continued to landing. During this time, the 'B' hydraulic system was functioning normal and the brake accumulator pressure was normal. This was verified and called out by the first officer just prior to landing. Also, during this time, the first officer was reading and accomplishing the checklist items. Landing was smooth and within the normal touchdown zone. I applied brakes evenly and slowly and used the #1 reverser. Shortly after the first brake application, someone from another airplane called on the radio that we had a brake fire. I relaxed the brakes momentarily and increased reverse thrust but then went back on the brakes. The airplane was tracking down the centerline of the runway. Shortly after we had decelerated below 60 KTS, the brakes failed completely. The 'B' hydraulic system had depleted. There was no way to steer or stop the airplane. The airplane started to slowly veer to the left. I discontinued the use of reverse thrust but the airplane continued off the runway and across the parallel taxiway and did not seem to be slowing. The airplane was rolling toward a steep dropoff, so I used reverse thrust on #1 engine to steer it toward an embankment. It went into a ditch at the approximately speed of a normal jog, struck the embankment and came to a stop. The flight attendants shouted 'brace' when they felt the airplane traveling on the rough surface. The first officer and I completed our evacuate/evacuation checks. I shut the engines down using the fire switches and discharged the fire extinguisher bottles. I then gave the evacuate/evacuation order several times on the PA. The evacuate/evacuation was executed beautifully with both the flight attendants and the passenger doing a great job. There was no screaming or panic. There were 100 passenger on the airplane, but the evacuate/evacuation took only about 1 min. My concerns are: although it is legal, I question whether the B737 should be dispatched with inoperative thrust reversers. The lack of any type guidance on total loss of brakes andsteering. Why the brake accumulators did not provide sufficient pressure to stop the airplane. (This was the second such occurrence I know of in the past 6 months.) callback conversation with reporter revealed the following information: the reporter stated the cause of the 'a' hydraulic failure was a cracked case on an engine driven hydraulic pump and the 'B' system failure on the ground was a outboard brake flexible line failure. The reporter said the aircraft was kept in alignment with the runway by using the left reverser. The reporter stated neither the NTSB nor the FAA has classified this event as an accident. Callback conversation with reporter acn 418792 revealed the following information: the reporter stated that not much information was given to the reporter on what components failed.
Original NASA ASRS Text
Title: A B737-200 ATTEMPTING AN EMER LNDG DUE TO LOSS OF 'A' SYS HYDS ON ROLLOUT HAS THE 'B' SYS FAIL RESULTING IN A RWY AND TXWY EXCURSION.
Narrative: I ARRIVED AT THE AIRPLANE ABOUT 50 MINS BEFORE DEP TIME, MET THE FO AND FLT ATTENDANTS, AND THEN WENT TO THE TICKET COUNTER TO OBTAIN THE DISPATCH RELEASE. DISPATCH HAD LEFT A MESSAGE TO CALL, AND WHEN I DID, THEY INFORMED ME OF AN ADDITIONAL ITEM TO ADD TO THE RELEASE, WHICH WAS THAT THE #2 ENG THRUST REVERSER WAS INOP. THE RELEASE CALLED FOR 31000 LBS OF FUEL, BUT I REQUESTED 29000 LBS, WHICH WAS STILL WELL ABOVE THE MINIMUM. DURING THE WALKAROUND INSPECTION, THE FO DISCOVERED THAT THE HYD QUANTITY WAS LOW. I REQUESTED THAT MAINT SVC THE HYDS, WHICH THEY DID, BUT A LOGBOOK ENTRY TO THAT EFFECT WAS NOT MADE. THE FLT DEPARTED ON TIME AND EVERYTHING WAS NORMAL UNTIL CLBING THROUGH FL180, WHEN I NOTICED THAT THE HYD QUANTITY WAS LOW AND WAS APCHING ZERO. THE 'A' HYD SYS LOW PRESSURE LIGHTS CAME ON AND THE 'A' HYD PRESSURE DROPPED TO ZERO. WE ADVISED ATC AND REQUESTED A RETURN TO ATL. I ADVISED ATC THAT WE NEEDED A LONG STRAIGHT-IN APCH AND THEY ADVISED THAT WE WERE THEN TURNING ONTO A STRAIGHT-IN APCH AND THEY ASKED IF WE WANTED RWY 9L OR RWY 9R. WE SELECTED RWY 9L, WHICH WAS THE LONGEST RWY AT ATL AND PICKED UP THE RWY VISUALLY AT ABOUT 15 MI OUT. WE WERE THEN CLRED FOR A VISUAL APCH. I THEN DECLARED AN EMER AND REQUESTED THE EMER EQUIP. I THEN MADE ANOTHER PA ANNOUNCEMENT TO THE PAX AND ADVISED THEM THAT EMER EQUIP WOULD BE RESPONDING BUT THAT IT WAS JUST A PRECAUTION. WE WERE SLIGHTLY HIGH ON THE APCH, SO I REQUESTED THAT THE FO EXTEND THE LNDG GEAR THEN, WHICH WAS OUT OF SEQUENCE, BUT I NEEDED THE ADDITIONAL DRAG TO SLOW THE AIRPLANE. HE EXTENDED THE GEAR USING THE EMER EXTENSION METHOD. I THEN SLOWED TO FLAP EXTENSION SPD AND HE BEGAN TO EXTEND THE FLAPS USING THE EMER METHOD. FLAPS WERE EXTENDING VERY SLOWLY, WHICH IS NORMAL USING THIS METHOD, BUT I WAS CONCERNED THAT WE WOULD NOT REACH 15 DEGS (LNDG FLAPS) IN TIME FOR A STABILIZED APCH, SO I REQUESTED A 360 DEG TURN, WHICH TWR COULD NOT APPROVE AT THAT TIME DUE TO TFC. A SHORT TIME LATER, THE TWR ADVISED THAT THEY COULD MOVE THE OTHER TFC AND WE COULD MAKE THE 360 DEG TURN. BY THAT TIME THE FLAPS WERE AT 15 DEGS, SO I ELECTED NOT TO MAKE THE TURN AND CONTINUED TO LNDG. DURING THIS TIME, THE 'B' HYD SYS WAS FUNCTIONING NORMAL AND THE BRAKE ACCUMULATOR PRESSURE WAS NORMAL. THIS WAS VERIFIED AND CALLED OUT BY THE FO JUST PRIOR TO LNDG. ALSO, DURING THIS TIME, THE FO WAS READING AND ACCOMPLISHING THE CHKLIST ITEMS. LNDG WAS SMOOTH AND WITHIN THE NORMAL TOUCHDOWN ZONE. I APPLIED BRAKES EVENLY AND SLOWLY AND USED THE #1 REVERSER. SHORTLY AFTER THE FIRST BRAKE APPLICATION, SOMEONE FROM ANOTHER AIRPLANE CALLED ON THE RADIO THAT WE HAD A BRAKE FIRE. I RELAXED THE BRAKES MOMENTARILY AND INCREASED REVERSE THRUST BUT THEN WENT BACK ON THE BRAKES. THE AIRPLANE WAS TRACKING DOWN THE CTRLINE OF THE RWY. SHORTLY AFTER WE HAD DECELERATED BELOW 60 KTS, THE BRAKES FAILED COMPLETELY. THE 'B' HYD SYS HAD DEPLETED. THERE WAS NO WAY TO STEER OR STOP THE AIRPLANE. THE AIRPLANE STARTED TO SLOWLY VEER TO THE L. I DISCONTINUED THE USE OF REVERSE THRUST BUT THE AIRPLANE CONTINUED OFF THE RWY AND ACROSS THE PARALLEL TXWY AND DID NOT SEEM TO BE SLOWING. THE AIRPLANE WAS ROLLING TOWARD A STEEP DROPOFF, SO I USED REVERSE THRUST ON #1 ENG TO STEER IT TOWARD AN EMBANKMENT. IT WENT INTO A DITCH AT THE APPROX SPD OF A NORMAL JOG, STRUCK THE EMBANKMENT AND CAME TO A STOP. THE FLT ATTENDANTS SHOUTED 'BRACE' WHEN THEY FELT THE AIRPLANE TRAVELING ON THE ROUGH SURFACE. THE FO AND I COMPLETED OUR EVAC CHKS. I SHUT THE ENGS DOWN USING THE FIRE SWITCHES AND DISCHARGED THE FIRE EXTINGUISHER BOTTLES. I THEN GAVE THE EVAC ORDER SEVERAL TIMES ON THE PA. THE EVAC WAS EXECUTED BEAUTIFULLY WITH BOTH THE FLT ATTENDANTS AND THE PAX DOING A GREAT JOB. THERE WAS NO SCREAMING OR PANIC. THERE WERE 100 PAX ON THE AIRPLANE, BUT THE EVAC TOOK ONLY ABOUT 1 MIN. MY CONCERNS ARE: ALTHOUGH IT IS LEGAL, I QUESTION WHETHER THE B737 SHOULD BE DISPATCHED WITH INOP THRUST REVERSERS. THE LACK OF ANY TYPE GUIDANCE ON TOTAL LOSS OF BRAKES ANDSTEERING. WHY THE BRAKE ACCUMULATORS DID NOT PROVIDE SUFFICIENT PRESSURE TO STOP THE AIRPLANE. (THIS WAS THE SECOND SUCH OCCURRENCE I KNOW OF IN THE PAST 6 MONTHS.) CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE CAUSE OF THE 'A' HYD FAILURE WAS A CRACKED CASE ON AN ENG DRIVEN HYD PUMP AND THE 'B' SYS FAILURE ON THE GND WAS A OUTBOARD BRAKE FLEXIBLE LINE FAILURE. THE RPTR SAID THE ACFT WAS KEPT IN ALIGNMENT WITH THE RWY BY USING THE L REVERSER. THE RPTR STATED NEITHER THE NTSB NOR THE FAA HAS CLASSIFIED THIS EVENT AS AN ACCIDENT. CALLBACK CONVERSATION WITH RPTR ACN 418792 REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT NOT MUCH INFO WAS GIVEN TO THE RPTR ON WHAT COMPONENTS FAILED.
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.