Estado: | Accident investigation report completed and information captured |
Fecha: | domingo 26 mayo 1991 |
Hora: | 23:17 |
Tipo: |  Boeing 767-3Z9ER |
Operador: | Lauda Air |
Registración: | OE-LAV |
Numéro de série: | 24628/283 |
Año de Construcción: | 1989-09-26 (1 year 8 months) |
Horas Totales de la Célula: | 7429 |
Ciclos: | 1132 |
Motores: | 2 Pratt & Whitney PW4060 |
Tripulación: | Fatalidades: 10 / Ocupantes: 10 |
Pasajeros: | Fatalidades: 213 / Ocupantes: 213 |
Total: | Fatalidades: 223 / Ocupantes: 223 |
Daños en la Aeronave: | Destruido |
Consecuencias: | Written off (damaged beyond repair) |
Ubicación: | 5,6 km (3.5 milles) NNE of Phu Toey ( Tailandia)
|
Fase: | En ruta (ENR) |
Naturaleza: | Vuelo Internacional Programado |
Aeropuerto de Salida: | Bangkok-Don Muang International Airport (BKK/VTBD), Tailandia |
Aeropuerto de Llegada: | Wien-Schwechat International Airport (VIE/LOWW), Austria |
Número de Vuelo: | NG004 |
Descripción:Lauda Air Flight 004 was a scheduled service from Hong Kong (HKG) back to Vienna (VIE), Austria. An intermediate stop was made in Bangkok (BKK), Thailand. The flight departed Bangkok at 23:02 hours. Some five minutes after takeoff the pilot-in-command stated "that keeps coming on," referring to a REV ISLN advisory warning. This indication appears when a fault has been detected in the thrust reverser system. The crew discussed the REV ISLN indication for about four and one-half minutes. The co-pilot read information from the Airplane Quick Reference Handbook as follows: "Additional systems failures may cause in- flight deployment" and "Expect normal reverser operation after landing." The pilot-in-command remarked "....its not just on, its coming on and off," he said, "...its just an advisory thing...," and shortly thereafter stated, "could be some moisture in there or something." At 23:12, the co-pilot advised the pilot-in-command that there was need for, "a little bit of rudder trim to the left." Fifteen minutes and one second into the flight the co-pilot exclaimed, "ah reverser's deployed," accompanied by sound similar to airframe shuddering, sounds of metallic snaps and the pilot-in-command stating "here wait a minute." With the deployment of the no. 1 engine thrust reverser, engine thrust was reduced to idle. Aerodynamic effects of the reverser plume in-flight during the engine run down to idle resulted in a 25 percent lift loss across the wing. The airplane stalled and entered an uncontrolled descent. Buffeting, maneuvering overload, and excessive speed caused pieces of the rudder and the left elevator to separate. This was followed by the down-and-aft separation of most of the right horizontal stabilizer from maneuvering overloads, as the crew attempted to control the airplane and arrest the high-speed descent. A torsional overload then caused the separation of the vertical and left horizontal stabilizers. The loss of the tail resulted in a sharp nose-over of the airplane, producing excessive negative loading of the wing. A downward wing failure was probably followed by the breakup of the fuselage. The complete breakup of the tail, wing, and fuselage occurred in a matter of seconds. The wreckage fell in mountainous jungle terrain.
Probable Cause:
PROBALE CAUSE: "The Accident Investigation Committee of the Government of Thailand determines the probable cause of this accident to be uncommanded in-flight deployment of the left engine thrust reverser, which resulted in loss of flight path control. The specific cause of the thrust reverser deployment has not been positively identified."
Fuentes:
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SKYbrary » Aviation Week & Space Technology 03.06.1991 (32), 10.06.91 (28-30)
Subsiguiente / acciones de seguridad
The Thai Aircraft Accident Investigation Committee recommended that the United States FAA examine the certification philosophy of all airplane certificated with ground only engine thrust reverser systems to provide appropriate design safeguards to prevent in-flight deployment.
The Aircraft Accident Investigation Committee also recommends that the FAA revise the certification standards for current and future airplane flight recorders intended for use in accident investigation to protect and preserve the recorded information from the conditions of prolonged thermal exposure that can be expected in accidents which occur in locations that are inaccessible for fire fighting efforts.
FAA issued 6 Airworthiness Directives
NTSB issued 4 Safety Recommendations
Issued: 03-JUL-1991 | To: FAA | A-91-45 |
CONDUCT A CERTIFICATION REVIEW OF THE PW4000 ENGINE-EQUIPPED BOEING 767 AIRPLANE THRUST REVERSER SYSTEMS TO EVALUATE ELECTRICAL AND MECHANICAL ANOMALIES AND FAILURE MODES THAT CAN ALLOW DIRECTIONAL CONTROL VALVE PRESSURE TO BE APPLIED TO THE REVERSER EXTEND PORT. THE CERTIFICATION REVIEW SHOULD INCLUDE SUBJECTING THE VALVE TO THE ENGINE\'S VIBRATION SPECTRUM CONCURRENT WITH INTRODUCTION OF INTERMITTENT PRESSURE SPIKES TO THE VALVE PRESSURE PORT. THE CERTIFICATION REVIEW SHOULD ALSO DETERMINE THE ADEQUACY OF THE THRUST REVERSER SYSTEM SAFEGUARDS WHEN THE HYDRAULIC ISOLATION VALVE IS OPEN TO PREVENT UNCOMMANDED THRUST REVERSER EXTENSIONS. (Closed - Acceptable Action) |
Issued: 03-JUL-1991 | To: FAA | A-91-46 |
AMEND THE BOEING 767 FLIGHT OPERATIONAL MANUAL ON AIRCRAFT POWERED BY THE PW4000 SERIES ENGINE TO INCLUDE IN SECTION, "REVERSER ISOLATION CAUTION LIGHT," A WARNING THAT IN-FLIGHT REVERSER DEPLOYMENT MAY RESULT IN SEVERE AIRFRAME BUFFETING, YAWING, AND ROLLING FORCES. (Closed - Acceptable Alternate Action) |
Issued: 03-JUL-1991 | To: FAA | A-91-47 |
PENDING COMPLETION OF A CERTIFICATION REVIEW OF THE THRUST REVERSER SYSTEM, ESTABLISH OPERATIONAL PROCEDURES TO BE FOLLOWED UPON ILLUMINATION OF THE REVERSE ISOLATION CAUTION LIGHT (REV ISLN) THAT WILL ENHANCE THE CONTROLLABILITY OF THE PW4000 POWERED BOEING 767 SHOULD A SECONDARY FAILURE RESULT IN THE IN-FLIGHT DEPLOYMENT OF A THRUST REVERSER. ACTIONS SHOULD BE TAKEN TO ACHIEVE AN APPROPRIATE COMBINATION OF AIRSPEED, ALTITUDE AND THRUST SETTINGS THAT WILL MINIMIZE CONTROL DIFFICULTIES IN THE EVENT THAT THE REVERSER SUBSEQUENTLY DEPLOYS. ALSO CONSIDER THE INCLUSION OF A PROCEDURE TO PULL THE FIRE HANDLE IF THIS OCCURS. IN LIEU OF IMPLEMENTATION OF REVISED OPERATIONAL PROCEDURES, OPERATORS MAY BE DIRECTED TO DEACTIVATE THRUST REVERSERS UNTIL THE CERTIFICATION REVIEW IS COMPLETED AND THE RELIABILITY OF THE SYSTEM CAN BE ADEQUATELY ASSURED. (Closed - Acceptable Action) |
Issued: 03-JUL-1991 | To: FAA | A-91-48 |
EXAMINE THE CERTIFICATION BASIS OF OTHER MODEL AIRPLANES EQUIPPED WITH ELECTRICALLY OR ELECTRO HYDRAULICALLY ACTUATED THRUST REVERSE SYSTEMS FOR APPROPRIATE SAFEGUARDS TO PREVENT INFLIGHT DEPLOYMENT OF REVERSERS AND ENSURE THAT OPERATING PROCEDURES ARE PROVIDED TO ENHANCE AIRCRAFT CONTROL IN THE EVENT OF AN INADVERTENT IN-FLIGHT REVERSE DEPLOYMENT. (Closed - Acceptable Action) |
Issued: 03-JUL-1991 | To: Boeing 767 | AD 91-15-09 |
B767 PW4000-engine fleet inspections and tests of thrust reverser systems. |
Issued: 15-AUG-1991 | To: Boeing 767 | AD T91-17-51 |
Requiring deactivation of thrust reversers on the 767 fleet. |
Issued: 23-AUG-1991 | To: Boeing 767 | AD T91-18-51 |
Allowed reactivation of reversers on GE and Rolls-Royce powered airplanes. Reverser deactivation on Pratt & Whitney powered airplanes remained in effect. |
Issued: 24-OCT-1991 | To: Boeing 767 | AD 91-22-09 |
Required the installation of, per Boeing Service Bulletin 767-78-0051: (1) independent stow and restow systems, (2) installation of an additional hydraulic isolation valve, and (3) modification of the electrical control system to make it less susceptible to electrical shorts induced by wire bundle chafing. Following this modification, reactivation of thrust reversers was allowed. |
Issued: 09-NOV-1991 | To: Boeing 767 | AD 92-24-03 |
Required, in addition to the requirements of AD 91-22-09, certain repetitive inspections, tests, adjustments, and functional tests of the thrust reverser control and indication system, and of selected engine wiring per Boeing Service Bulletin 767-78-0046. A specific check of the directional control valve "hot short" protection was included. |
Issued: 24-FEB-1994 | To: Boeing 767 | AD 94-12-10 |
Required the installation of a third locking system ("sync" locks) on 767 airplanes equipped with PW4000 engines, per Boeing Service Bulletin 767-78-0062. |
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Fotos

accident date:
26-05-1991type: Boeing 767-3Z9ER
registration: OE-LAV
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Bangkok-Don Muang International Airport to Wien-Schwechat International Airport as the crow flies is 8375 km (5235 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.