Crash-aerien 20 DEC 1995 d'un Boeing 747-136 N605FF - New York-John F. Kennedy International Airport, NY (JFK)

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Accident

Last updated: 20 June 2013

Statuts:	Enquête Officielle
Date:	20 DEC 1995
Heure:	11:36 EST
Type/Sous-type:	Boeing 747-136
Compagnie:	Tower Air
Immatriculation:	N605FF
Numéro de série:	20271/172
Année de Fabrication:	1971-12-03 (24 years )
Heures de vol:	90456
Cycles:	17726
Moteurs:	4 Pratt & Whitney JT9D-7A
Equipage:	victimes: 0 / à bord: 17
Passagers:	victimes: 0 / à bord: 451
Total:	victimes: 0 / à bord: 468
Dégats de l'appareil:	Substantiels
Conséquences:	Written off (damaged beyond repair)
Lieu de l'accident:	New York-John F. Kennedy International Airport, NY (JFK) (Etats-Unis d'Amérique)
Phase de vol:	Au décollage (TOF)
Nature:	Transport de Passagers Nat.
Aéroport de départ:	New York-John F. Kennedy International Airport, NY (JFK/KJFK), Etats-Unis d'Amérique
Aéroport de destination:	Miami International Airport, FL (MIA/KMIA), Etats-Unis d'Amérique
Numéro de vol:	41

Détails:
Flight 41, bound for Miami was pushed back from the gate at 10:36. At 11:00 de-icing procedures were started at 11:00, using both Type I and Type II fluids. The crew received clearance for runway 04L at 11:16 and started to taxi slowly towards the assigned runway. The aircraft was stopped on the taxiway to clear the engines of any ice by increasing power to 45% N1 for 10 seconds. The aircraft continued and the flight was cleared to taxi in position and hold at 11:32 and got take-off clearance at 11:36.
The take-off was normal, until shortly before 80 knots. The aircraft started to move to the left; corrections by the crew were ineffective. The captain then aborted the takeoff by retarding power levers to idle and by applying maximum braking. He didn't use reverse thrust, because of the slow speed, long runway and the possibility that it could worsen directional control. At 2100 feet past the threshold, the 747 departed the left side of the runway. The aircraft finally struck a transformer, causing the no,4 engine to separate. The Boeing came to rest at 4800 feet past the threshold and 600 feet to the left of the runway centreline with the nosegear collapsed.

PROBABLE CAUSE" The captain's failure to reject the takeoff in a timely manner when excessive nose wheel steering tiller inputs resulted in a loss of directional control on a slippery runway. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air, Inc., and the Boeing Commercial Airplane Group and the inadequate fidelity of Boeing 747 flight training simulators for slippery runway operations contributed to the cause of this accident.
The captain's reapplication of forward thrust before the airplane departed the left side of the runway contributed to the severity of the runway excursion and damage to the airplane."

Sources:
» NTSB Safety Recommendations A-96-45 through -47
» NTSB/AAR-96/04
» Captain Rejects Takeoff as Boeing 747 Veers off Slippery Runway (Flight Safety Foundation - Accident Prevention March 1997)

Official accident investigation report

investigating agency:	National Transport Safety Bureau (NTSB) - USA
report status:	Final
report number:	NTSB/AAR-96-04
report released:	02-DEC-1996
duration of investigation:	348 days (11.6 months)
download report:	Runway Departure During Attempted Takeoff, Tower Air Flight 41 Boeing 747-136, N605FF, JFK International Airport, New York, December 20, 1995 (NTSB/AAR-96-04)

Opérations de secours

NTSB issued 19 Safety Recommendations

Issued: 11-JUL-1996	To: FAA	A-96-045
REQUIRE THAT THE OPERATORS OF ALL AIRPLANES EQUIPPED WITH A TELEDYNE CONTROLS AERONAUTICAL RADIO INCORPORATED 563 DIGITAL FLIGHT DATA RECORDER SYSTEM PERFORM A SELF TEST OF THE CENTRAL ELECTRONICS UNIT EACH FLIGHT DAY TO ENSURE THAT THE SYSTEM IS OPERATING PROPERLY. (Closed - Acceptable Alternate Action)
Issued: 11-JUL-1996	To: FAA	A-96-046
MODIFY MASTER MINIMUM EQUIPMENT LISTS TO ENSURE THAT FLIGHT WITH AN INOPERATIVE FLIGHT DATA RECORDER IS PERMITTED ONLY UNITL THE AIRPLANE\'S FIRST ARRIVAL AT A SUITABLE REPAIR FACILITY, BUT NOT TO EXCEED 3 DAYS. (Closed - Acceptable Action)
Issued: 11-JUL-1996	To: FAA	A-96-047
INCREASE OVERSIGHT OF FLIGHT DATA RECORDER SYSTEM MAINTENANCE PRACTICES BY TOWER AIR TO ENSURE THAT REPAIRS ARE PERFORMED IN ACCORDANCE WITH THE MAINTENANCE MANUAL. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-150
REQUIRE MODIFICATION OF APPLICABLE OPERATING PROCEDURES PUBLISHED BY THE BOEING COMMERCIAL AIRPLANE GROUP AND AIR CARRIER OPERATORS OF THE B-747 TO FURTHER CAUTION FLIGHTCREWS AGAINST USE OF THE TILLER DURING SLIPPERY RUNWAY OPERATIONS, INCLUDING LOW-SPEED OPERATIONS (FOR AIRPLANE EQUIPPED WITH RUDDER PEDAL STEERING) AND TO PROVIDE APPROPRIATE LIMITATIONS ON TILLER USE DURING THESE OPERATION (FOR AIRPLANES NOT EQUIPPED WITH RUDDER PEDAL STEERING). (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-151
ISSUE A FLIGHT STANDARDS INFO BULLETIN TO PRINCIPAL OPERATIONS INSPECTORS ASSIGNED TO AIR CARRIER OPERATING THE B-747, INFORMING THEM OF THE CIRCUMSTANCES OF THIS ACCIDENT & REQUESTING A REVIEW & MODIFICATION, AS REQUIRED, OF EACH AIR CARRIER\'S TAKEOFF PROCEDURE REGARDING PILOT HAND POSITION WITH RESPECT TO THE TILLER. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-152
REQUIRE THE BOEING COMMERCIAL AIRPLANE GROUP TO DEVELOP OPERATIONALLY USEFUL CRITERIA FOR MAKING A RAPID & ACCURATE DECISION TO REJECT A TAKEOFF UNDER SLIPPERY RUNWAY CONDITIONS; THEN REQUIRE THAT B-747 AIRCRAFT FLIGHT MANUALS, OPERATING MANUALS, & TRAINING MANUALS BE REVISED ACCORDINGLY. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-153
EVALUATE BOEING 747 SIMULATOR GROUND HANDLING MODELS & OBTAIN ADDITIONAL GROUND HANDLING DATA, AS REQUIRED, TO ENSURE THAT B-747 FLIGHT SIMULATORS USED FOR AIR CARRIER FLIGHTCREW TRAINING ACCURATELY SIMULATE THE SLIPPERY RUNWAY HANDLING CHARACTERISTICS OF THE AIRPLANE. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-154
AFTER COMPLETING THIS EVALUATION, ISSUE A FLIGHT STANDARDS INFO BULLETIN URGING PRINCIPAL OPERATIONS INSPECTORS ASSIGNED TO AIR CARRIER OPERATORS OF THE BOEING 747 TO ENHANCE SIMULATOR TRAINING FOR SLIPPERY RUNWAY OPERATIONS, INCLUDING LIMITATIONS ON TILLER USE & INSTRUCTIONS FOR RUDDER USE DURING THE TAKEOFF ROLL. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-155
DEVELOP CERTIFICATION STANDARDS FOR THE INSTALLATION OF SECONDARY GALLEY LATCHES; THEN USE THOSE STANDARDS TO CONDUCT AN ENGINEERING REVIEW OF SECONDARY GALLEY LATCHES ON ALL TRANSPORT-CATEGORY AIRCRAFT. REQUIRE CHANGES TO EXISTING INSTALLATIONS AS NECESSARY TO ENSURE THAT THE STRENGTH OF SECONDARY LATCHES & THEIR INSTALLATION ARE SUFFICIENT TO ADEQUATELY RESTRAIN CARTS. (Closed - Unacceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-156
ISSUE A FLIGHT STANDARDS INFO BULLETIN TO PRINCIPAL OPERATIONS INSPECTORS OF 14 CFR PART 121 AIR CARRIERS TO ENSURE THAT FLIGHT ATTENDANTTRAINING PROGRAMS STRESS THE IMPORTANCE OF SHOUTING THE APPROPRIATE PROTECTIVE INSTRUCTIONS AT THE FIRST INDICATION OF A POTENTIAL ACCIDENT, EVEN WHEN FLIGHT ATTENDANTS ARE UNCERTAIN OF THE PRECISE NATURE OF THE SITUATION. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-157
ISSUE A FLIGHT STANDARDS INFO BULLETIN REQUIRING PRINCIPAL OPERATIONS INSPECTORS OF 14 CFR PART 121 AIR CARRIERS TO ENSURE THAT THEIR AIR CARRIERS HAVE ADEQUATE PROCEDURES FOR FLIGHT ATTENDANT COMMUNICATIONS, INCLUDING THOSE FOR COORDINATING EMERGENCY COMMANDS TO PASSENGERS, TRANSMITTING INFO TO FLIGHTCREWS & OTHER FLIGHT ATTENDANTS, & HANDLING POSTACCIDENT ENVIRONMENTS IN WHICH NORMAL COMMUNICATIONS SYSTEMS HAVE BEEN DISRUPTED. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-158
ISSUE A FLIGHT STANDARDS INFO BULLETIN THAT ENCOURAGES THE USE OF THIS ACCIDENT AS A CASE STUDY FOR CREW RESOURCE MANAGEMENT TRAINING. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-159
REVIEW THE STRUCTURE AND PERFORMANCE OF THE CONTINUING AIRWORTHINESS SURVEILLANCE & RELIABILITY PROGRAMS IN THE TOWER AIR MAINTENANCE DEPARTMENT. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-160
Reassess inspectors\' methods of evaluating maintenance work, focusing on the possibility of false entries through selective detailed analysis of records and unannounced work site inspections. (Superseded by A-97-15) (Closed - Unacceptable Action/Superseded)
Issued: 20-DEC-1996	To: FAA	A-96-161
REVISE 14 CFR PART 119 TO SPECIFY THAT THE CHIEF PILOT & ALL OPERATIONAL FUNCTIONS UNDER THAT POSITIONS REPORT THROUGH THE DIRECTOR OF OPERATIONS. (Closed - Acceptable Alternate Action)
Issued: 20-DEC-1996	To: FAA	A-96-162
IMMEDIATELY IMPLEMENT THE PLAN TO ASSIGN THE TOWER AIR CERTIFICATE TO A PRINCIPAL OPERATIONS INSPECTOR (PIO) & ASSISTANT POI WHO DO NOT HAVE OVERSIGHT RESPONSIBILITY FOR ANY OTHER CARRIERS. (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-163
DEVELOP, 12/31/97, STANDARDS FOR ENHANCED SURVEILLANCE OF AIR CARRIERS BASED ON RAPID GROWTH, CHANGE, COMPLEXITY, AND ACCIDENT/INCIDENT HISTORY; THEN REVISE NATIONAL FLIGHT STANDARDS SURVEILLANCE METHODS, WORK PROGRAMS, STAFFING STANDARDS, AND INSPECTOR STAFFING TO ACCOMPLISH THE ENHANCED SURVEILLANCE THAT IS IDENTIFIED BY THE NEW STANDARDS (Closed - Acceptable Action)
Issued: 20-DEC-1996	To: FAA	A-96-164
REQUIRE THE APPROPRIATE AVIATION RULEMAKING & ADVISORY COMMITTEE TO ESTABLISH RUNWAY FRICTION MEASUREMENTS THAT ARE OPERATIONALLY MEANINGFUL TO PILOTS & AIR CARRIERS FOR THEIR SLIPPERY RUNWAY OPERATIONS ( INCLUDING A TABLE CORRELATING FRICTION VALUES MEASURED BY VARIOUS TYPES OF INDUSTRY EQUIPMENT), & MINIMUM COEFFICIENT OF FRICTION LEVELS FOR SPECIFIC AIRPLANE TYPES BELOW WHICH AIRPLANE OPERATIONS WILL BE SUSPENDED. (Closed - Reconsidered)
Issued: 20-DEC-1996	To:	A-96-165
THE NTSB RECOMMENDS THAT THE TOWER AIR, INC." REVISE TOWER AIR\'S INITIAL FLIGHT ATTENDANT TRAINING PROGRAM TO INCLUDE "HANDS-ON" TRAINING FOR SECURING EACH TYPE OF GALLEY & CART INCLUDED IN ITS BOEING 747 FLEET. (Closed - Acceptable Action)

Show all AD's and Safety Recommendations

Photos

Photo By Michael F. McLaughlin / MikePhotos Airliner Images

Plan

Ce plan montre l'aéroport de départ ainsi que la supposé destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre New York-John F. Kennedy International Airport, NY et Miami International Airport, FL est de 1745 km (1091 miles).

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