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|
Attributes | |
ACN | 687555 |
Time | |
Date | 200602 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Fog |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tower : lax.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 70 flight time total : 8000 flight time type : 3000 |
ASRS Report | 687555 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 75 flight time total : 5000 flight time type : 75 |
ASRS Report | 687371 |
Events | |
Anomaly | aircraft equipment problem : critical excursion : runway non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : abs warning other flight crewa |
Resolutory Action | none taken : unable none taken : insufficient time |
Consequence | other other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : inspection performance deficiency : fault isolation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Weather Maintenance Human Performance |
Primary Problem | Ambiguous |
Narrative:
I am a high minimums captain. The airport was switching runways due to WX. So my first officer and I elected to go into holding until a better alternative came about. Winds were 300 degrees at 8 KTS; visibility 2 mi; 8000 ft overcast. They switched the runway to runway 15R (11515 ft long). Landing weight 454000 ls. The load planning computer stated good to 458000 pounds with tailwind and wet runway. Normal approach intercepted final 6 mi prior to FAF on GS; on speed. Flaps 50 degrees; medium autobrakes; 158 KT bug speed. Touchdown in touchdown zone; spoilers deployed and thrust reversers deployed. When spoilers went to full; the autobrake system fail light illuminated and first officer called spoilers deployed; autobrake system fail. I immediately applied manual braking. With no sense of brake pressure; first officer called 80 KTS. I asked for help on brakes -- both to no avail. Toe brakes were on the floor. No brake pressure. The aircraft continued down the runway until we went into the overrun. And the nosewheel went into the dirt; slightly left of centerline. Parameters: wind at touchdown within limits. Disconnected autoplt about 1000 ft; bug speed on speed; on localizer; on glide path. It felt that there was no brake pressure from midfield until we ran off the end and finally stopped. I believe the runway excursion was due to a loss of brake system on aircraft. Since the event happened in a foreign country; I was making sure that the passenger and crew were being treated to. Right before I was about to leave the aircraft; the foreign civil air safety team came onto the aircraft. It was a 3-MAN team. One officer was asking me questions and the others were inspecting the logbook. Then I was released from the aircraft. So in leaving; I never had a chance to do a write-up in the logbook about the brake failure or runway excursion due to the fact that the government officers had taken the logbook and I did not have access to them at the time; due to the fact that they were absent from the airplane while they were inspecting the logbook. I should have written them up before he took the logbook; but I was still handling my other duties as captain. Postflt; maintenance said they showed no faults in the brake system. But after the fact; I have come to find out that the maintenance department changed out the anti-skid controller and valves. They also changed out the autobrake controller and valves and screens and all the components of the autobrake system were replaced. My error was that I did not write up event in logbook. The problem arose due to the fact it happened in a foreign country under their laws and dealing with multiple people at one time. I recalled not writing it up at hotel; but was already off airport premise. I should have slowed down and asked the government officials to not take the logbook until I was finished. Supplemental information from acn 687371: aircraft nosewheel ran into the overrun zone and broke through the concrete into the mud. This was a very rough ride and a flight attendant was injured in the R2 door seat. Injury was from an 'exit' sign and loose object falling on her. The main gear (approximately 100 ft aft of the nosewheel) remained on the actual runway hard surface. Brake temperatures were all below the lows 200's (unusually low). There were no flat spots on the mains. We completed lndgs in the simulator under duplicated conditions and the aircraft was brought to a halt every time except for the simulated brake failure. Under that scenario; we departed the end at 45 KTS. Very close to the incident speed that day. There is a little known procedure that says: 'if brakes do not function normally; release the brake pedals and move antiskid switch to 'off;' re-apply brakes and increase reverse thrust; as required....' callback conversation with reporter acn 687555 revealed the following information: the first officer reported that once the inappropriate removal and replacement of multiple system components was done; the sole remaining potential source of system failure information was the fdr. The first officer advised the recorder had been examined by maintenance staffs of 2 different airlines; both of which were stymied in their attempts to read beyond a series of errorcodes prior to the event in question. The recorder has been forwarded to the aircraft manufacturer in hopes that they will be able to do so.
Original NASA ASRS Text
Title: UNABLE TO STOP AFTER TOUCHDOWN; MD11 LNDG IN MODERATE RAIN ON A WET; UNGROOVED RWY AT XXX; FO; ROLLS ONTO OVERRUN AND NOSE GEAR BREAKS THROUGH CONCRETE. FAULTY MAINT PROCS ENSUE; RESULTING IN UNKNOWN SOURCE OF PROB.
Narrative: I AM A HIGH MINIMUMS CAPT. THE ARPT WAS SWITCHING RWYS DUE TO WX. SO MY FO AND I ELECTED TO GO INTO HOLDING UNTIL A BETTER ALTERNATIVE CAME ABOUT. WINDS WERE 300 DEGS AT 8 KTS; VISIBILITY 2 MI; 8000 FT OVCST. THEY SWITCHED THE RWY TO RWY 15R (11515 FT LONG). LNDG WT 454000 LS. THE LOAD PLANNING COMPUTER STATED GOOD TO 458000 LBS WITH TAILWIND AND WET RWY. NORMAL APCH INTERCEPTED FINAL 6 MI PRIOR TO FAF ON GS; ON SPD. FLAPS 50 DEGS; MEDIUM AUTOBRAKES; 158 KT BUG SPD. TOUCHDOWN IN TOUCHDOWN ZONE; SPOILERS DEPLOYED AND THRUST REVERSERS DEPLOYED. WHEN SPOILERS WENT TO FULL; THE AUTOBRAKE SYS FAIL LIGHT ILLUMINATED AND FO CALLED SPOILERS DEPLOYED; AUTOBRAKE SYS FAIL. I IMMEDIATELY APPLIED MANUAL BRAKING. WITH NO SENSE OF BRAKE PRESSURE; FO CALLED 80 KTS. I ASKED FOR HELP ON BRAKES -- BOTH TO NO AVAIL. TOE BRAKES WERE ON THE FLOOR. NO BRAKE PRESSURE. THE ACFT CONTINUED DOWN THE RWY UNTIL WE WENT INTO THE OVERRUN. AND THE NOSEWHEEL WENT INTO THE DIRT; SLIGHTLY L OF CTRLINE. PARAMETERS: WIND AT TOUCHDOWN WITHIN LIMITS. DISCONNECTED AUTOPLT ABOUT 1000 FT; BUG SPEED ON SPEED; ON LOC; ON GLIDE PATH. IT FELT THAT THERE WAS NO BRAKE PRESSURE FROM MIDFIELD UNTIL WE RAN OFF THE END AND FINALLY STOPPED. I BELIEVE THE RWY EXCURSION WAS DUE TO A LOSS OF BRAKE SYS ON ACFT. SINCE THE EVENT HAPPENED IN A FOREIGN COUNTRY; I WAS MAKING SURE THAT THE PAX AND CREW WERE BEING TREATED TO. RIGHT BEFORE I WAS ABOUT TO LEAVE THE ACFT; THE FOREIGN CIVIL AIR SAFETY TEAM CAME ONTO THE ACFT. IT WAS A 3-MAN TEAM. ONE OFFICER WAS ASKING ME QUESTIONS AND THE OTHERS WERE INSPECTING THE LOGBOOK. THEN I WAS RELEASED FROM THE ACFT. SO IN LEAVING; I NEVER HAD A CHANCE TO DO A WRITE-UP IN THE LOGBOOK ABOUT THE BRAKE FAILURE OR RWY EXCURSION DUE TO THE FACT THAT THE GOV OFFICERS HAD TAKEN THE LOGBOOK AND I DID NOT HAVE ACCESS TO THEM AT THE TIME; DUE TO THE FACT THAT THEY WERE ABSENT FROM THE AIRPLANE WHILE THEY WERE INSPECTING THE LOGBOOK. I SHOULD HAVE WRITTEN THEM UP BEFORE HE TOOK THE LOGBOOK; BUT I WAS STILL HANDLING MY OTHER DUTIES AS CAPT. POSTFLT; MAINT SAID THEY SHOWED NO FAULTS IN THE BRAKE SYS. BUT AFTER THE FACT; I HAVE COME TO FIND OUT THAT THE MAINT DEPT CHANGED OUT THE ANTI-SKID CONTROLLER AND VALVES. THEY ALSO CHANGED OUT THE AUTOBRAKE CONTROLLER AND VALVES AND SCREENS AND ALL THE COMPONENTS OF THE AUTOBRAKE SYS WERE REPLACED. MY ERROR WAS THAT I DID NOT WRITE UP EVENT IN LOGBOOK. THE PROB AROSE DUE TO THE FACT IT HAPPENED IN A FOREIGN COUNTRY UNDER THEIR LAWS AND DEALING WITH MULTIPLE PEOPLE AT ONE TIME. I RECALLED NOT WRITING IT UP AT HOTEL; BUT WAS ALREADY OFF ARPT PREMISE. I SHOULD HAVE SLOWED DOWN AND ASKED THE GOV OFFICIALS TO NOT TAKE THE LOGBOOK UNTIL I WAS FINISHED. SUPPLEMENTAL INFO FROM ACN 687371: ACFT NOSEWHEEL RAN INTO THE OVERRUN ZONE AND BROKE THROUGH THE CONCRETE INTO THE MUD. THIS WAS A VERY ROUGH RIDE AND A FLT ATTENDANT WAS INJURED IN THE R2 DOOR SEAT. INJURY WAS FROM AN 'EXIT' SIGN AND LOOSE OBJECT FALLING ON HER. THE MAIN GEAR (APPROX 100 FT AFT OF THE NOSEWHEEL) REMAINED ON THE ACTUAL RWY HARD SURFACE. BRAKE TEMPS WERE ALL BELOW THE LOWS 200'S (UNUSUALLY LOW). THERE WERE NO FLAT SPOTS ON THE MAINS. WE COMPLETED LNDGS IN THE SIMULATOR UNDER DUPLICATED CONDITIONS AND THE ACFT WAS BROUGHT TO A HALT EVERY TIME EXCEPT FOR THE SIMULATED BRAKE FAILURE. UNDER THAT SCENARIO; WE DEPARTED THE END AT 45 KTS. VERY CLOSE TO THE INCIDENT SPD THAT DAY. THERE IS A LITTLE KNOWN PROC THAT SAYS: 'IF BRAKES DO NOT FUNCTION NORMALLY; RELEASE THE BRAKE PEDALS AND MOVE ANTISKID SWITCH TO 'OFF;' RE-APPLY BRAKES AND INCREASE REVERSE THRUST; AS REQUIRED....' CALLBACK CONVERSATION WITH RPTR ACN 687555 REVEALED THE FOLLOWING INFO: THE FO RPTED THAT ONCE THE INAPPROPRIATE REMOVAL AND REPLACEMENT OF MULTIPLE SYS COMPONENTS WAS DONE; THE SOLE REMAINING POTENTIAL SOURCE OF SYS FAILURE INFO WAS THE FDR. THE FO ADVISED THE RECORDER HAD BEEN EXAMINED BY MAINT STAFFS OF 2 DIFFERENT AIRLINES; BOTH OF WHICH WERE STYMIED IN THEIR ATTEMPTS TO READ BEYOND A SERIES OF ERRORCODES PRIOR TO THE EVENT IN QUESTION. THE RECORDER HAS BEEN FORWARDED TO THE ACFT MANUFACTURER IN HOPES THAT THEY WILL BE ABLE TO DO SO.
Data retrieved from NASA's ASRS site as of January 2009 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.