Crash-aerien 01 NOV 1998 d'un Boeing 737-2P6 EI-CJW - Atlanta-William B. Hartsfield International Airport, GA (ATL)
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Statuts:Accident investigation report completed and information captured
Date:dimanche 1 novembre 1998
Heure:18:48
Type/Sous-type:Silhouette image of generic B732 model; specific model in this crash may look slightly different
Boeing 737-2P6
Compagnie:AirTran Airways
Immatriculation: EI-CJW
Numéro de série: 21355/493
Année de Fabrication: 1977-06-10 (21 years 5 months)
Heures de vol:45856
Cycles:49360
Moteurs: 2 Pratt & Whitney JT8D-17
Equipage:victimes: 0 / à bord: 5
Passagers:victimes: 0 / à bord: 100
Total:victimes: 0 / à bord: 105
Dégats de l'appareil: Substantiels
Conséquences: Written off (damaged beyond repair)
Lieu de l'accident:Atlanta-William B. Hartsfield International Airport, GA (ATL) (   Etats-Unis d'Amérique)
Phase de vol: A l'atterrissage (LDG)
Nature:Transport de Passagers Nat.
Aéroport de départ:Atlanta-William B. Hartsfield International Airport, GA (ATL/KATL), Etats-Unis d'Amérique
Aéroport de destination:Dallas-Love Field, TX (DAL/KDAL), Etats-Unis d'Amérique
Numéro de vol: 867
Détails:
The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine during a postflight inspection at Atlanta. AirTran mechanics identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. The AirTran maintenance controller in Orlando instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List (MEL) procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing on runway 09L. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch.

Probable Cause:

PROBABLE CAUSE: "(1) the capping of the incorrect hydraulic line by mechanics, which led to the failure of hydraulic system A; (2) the mechanics' lack of experience working with the Boeing 737 hydraulic system; and (3) the maintenance controller's failure to ascertain more information regarding the leaking hydraulic line before instructing the mechanics to cap the line and deactivate the right thrust reverser.
Contributing to the cause of the accident were (1) the asymmetric directional control resulting from the deactivation of the right thrust reverser; (2) the depletion of the left and right inboard brake accumulator pressure because of the flight crew's use of the rudder pedals with only the left thrust reverser to control the direction of the airplane down the runway; (3) the failure of the right outboard brake because the airplane was slowed without the use of the left and right inboard brakes and was traveling at a higher-than-normal speed and with heavy gross weight; (4) the failure of the right outboard brake after one of the right outboard pistons overtraveled and unported its o-ring, allowing system B hydraulic fluid to deplete and the left outboard brake to fail; and (5) the mechanics' improper use of the illustrated parts catalog for maintenance and troubleshooting and the maintenance controller's failure to use the appropriate documents for maintenance and troubleshooting."

Accident investigation:

cover
Investigating agency: NTSB
Status: Investigation completed
Duration: 4 years and 4 months
Accident number: DCA99MA007
Download report: Final report

Sources:
» NTSB


Photos

photo of Boeing-737-2P6-A4O-BC
accident date: 01-11-1998
type: Boeing 737-2P6
registration: A4O-BC
 

Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Atlanta-William B. Hartsfield International Airport, GA et Dallas-Love Field, TX est de 1151 km (719 miles).

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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