Status: | Accident investigation report completed and information captured |
Datum: | Dienstag 1 März 1994 |
Zeit: | 13:38 |
Flugzeugtyp: |  Boeing 747-251B |
Fluggesellschaft: | Northwest Airlines |
Kennzeichen: | N637US |
Werknummer: | 23548/644 |
Baujahr: | 1986-05-10 (7 years 10 months) |
Betriebsstunden: | 31798 |
Triebwerk: | 4 Pratt & Whitney JT9D-7R4G2 |
Besatzung: | Todesopfer: 0 / Insassen: 18 |
Fluggäste: | Todesopfer: 0 / Insassen: 227 |
Gesamt: | Todesopfer: 0 / Insassen: 245 |
Sachschaden: | schwer beschädigt |
Konsequenzen: | Repaired |
Unfallort: | Tokyo-Narita Airport (NRT) ( Japan)
|
Flugphase: | Landung (LDG) |
Betriebsart: | Internationaler Linienflug |
Flug von: | Hong Kong-Kai Tak International Airport (HKG/VHHH), |
Flug nach: | Tokyo-Narita Airport (NRT/RJAA), Japan |
Flugnummer: | 18 |
Unfallbericht:Northwest Airlines Flight 18 had departed from Hong Kong for a flight to New York-JFK with an intermediate stop at Tokyo-Narita, Japan. The flight, touchdown, and initial landing rollout at Narita, were routine. Engine thrust reversing was normal on all four engines until the flight crew moved the engine power levers out of reverse thrust at about 90 knots. During the rollout, the No. 1 engine and pylon rotated downward about the midspar pylon-to-wing fittings into a position in which the lower forward part of the engine nose cowl contacted the runway. The airplane was subsequently stopped on a taxiway, with the front of the No. 1 engine still contacting the ground. The lower forward engine nose cowl had been ground away as it slid along the runway. A fire near the No. 1 engine was rapidly extinguished by local fire fighters, and all passengers remained aboard. They were subsequently deplaned via portable boarding stairs about 30 minutes after the airplane was brought to a stop. There were no injuries.
Maintenance and inspection personnel who worked on the airplane were not adequately trained and qualified to perform the required maintenance and inspection functions. In addition, the work environment for the heavy maintenance of the airplane was inadequate and contributed to an effort producing situation for the workers.
Probable Cause:
PROBABLE CAUSE: "When C check of the aircraft was conducted, the retainer for the diagonal brace aft fuse pin of No.1 nacelle strut was removed and the aircraft was returned to service without reinstalling the retainer. In the course of the flights after this, the fuse pin moved, disconnecting the diagonal brace at the aft joint.
It is estimated that when the thrust reverser was deployed during the landing roll under such circumstances, the forward fuse pin of the upper link was fractured due to a load in excess of the design rupture strength, dangling the forward portion of No.1 engine and a fire on leaked oil and fuel broke out in the aft portion of the nacelle strut."
Accident investigation:

|
Investigating agency: | ARAIC Japan  |
Status: | Investigation completed |
Duration: | 2 years and 9 months | Download report: | Final report
|
|
Informationsquelle:
» NTSB/SIR-94/02
Sicherheitsempfehlungen
The NTSB made several recommendations to the Federal Aviation Administration concerning human engineering principles in maintenance operations, and the critical assessment of maintenance work environments. Recommendations were made to Northwest Airlines concerning the same subjects.
NTSB issued 9 Safety Recommendations
Issued: 11-JAN-1995 | To: FAA | A-94-218 |
REVIEW THE NORTHWEST AIRLINES CITEXT SYSTEM, AND WHERE PRACTICAL REQUIRE MODIFICATION OF THOSE SECTIONS THAT REFER TO ACTIONS, COMPONENTS, OR SYSTEMS THAT ARE SPECIFIC TO PARTICULARY AIRPLANES TO ENSURE THAT THE MAINTENANCE ACTION REQUESTED CONFORMS TO MAINTENANCE ACTION REQUIRED FOR THE SPECIFIC AIRPLANE. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: FAA | A-94-219 |
APPLY HUMAN ENGINEERING PRINCIPLES TO THE EVALUATION OF COMPUTER GENERATED WORK CARD SYSTEMS TO ENSURE THAT THEY INCLUDE ALL OF THE CRITICAL INFORMATION CONTAINED IN, AND ARE CONSISTENT WITH, THE FAA APPROVED MAINTENANCE MANUALS. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: FAA | A-94-220 |
INFORM OTHER AIRLINES OPERATING IN THE U.S., AND FOREIGN AIRWORTHINESS AUTHORITIES, OF THE CIRCUMSTANCES OF THIS ACCIDENT AND REQUIRE THEM TO IMPLEMENT CORRECTIVE ACTIONS, WHERE NECESSARY, TO PREVENT THE MAINTENANCE PROGRAM DEFICIENCIES NOTED IN THIS ACCIDENT. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: FAA | A-94-221 |
ASSESS THE WORK ENVIRONMENTS IN WHICH CARRIERS OPERATING UNDER 14 CODE OF FEDERAL REGULATIONS PART 121 PERFORM THEIR MAINTENANCE TO IDENTIFY HUMAN FACTORS-RELATED IMPEDIMENTS TO THE EFFECTIVE PERFORMANCE OF MAINTENANCE AND INSPECTIONS, SUCH AS INADEQUATE LIGHTING, POTENTIALLY HAZARDOUS SCAFFOLDING, AND INADEQUATE AND UNORGANIZED PARTS STORAGE DURING MAINTENANCE ACTIVITY, AND REQUIRE THOSE CARRIERS TO CORRECT THE DEFICIENCIES. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: FAA | A-94-222 |
DIRECT OPERATORS OF BOEING 747 AIRPLANES TO PAINT THE INSIDE SURFACES OF THE ENGINE PYLON FUSE PINS A CONSPICUOUS COLOR SUCH AS RED. (Closed--No Longer Applicable) |
Issued: 11-JAN-1995 | To: Northwest Airlines | A-94-223 |
REVIEW THE CITEX SYSTEM, AND, WHERE NECESSARY, REQUIRE THE MODIFICATION OF SECTIONS THAT REFER TO ACTIONS, COMPONENTS OR SYSTEMS THAT ARE SPECIFIC TO PARTICULAR AIRPLANES TO ENSURE THAT THE MAINTENANCE ACTION REQUESTED CONFORMS TO THE MAINTENANCE ACTION REQUIRED FOR THE SPECIFIC AIRPLANE. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: Northwest Airlines | A-94-224 |
APPLY HUMAN FACTORS ENGINEERING PRINCIPLES TO THE EVALUATION OF THE CITEX SYSTEM AND IMPLEMENT REVISIONS, AS NECESSARY, TO ENSURE THAT THE COMPUTER-GENERATED WORK CARDS ARE CONSISTENT WITH THE MATERIAL CONTAINED IN THE FAA-APPROVED MAINTENANCE MANUALS AND THAT THE SPECIFIED WORK OR INSPECTION REQUIREMENTS ARE CLEARLY STATED. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: Northwest Airlines | A-94-225 |
REVIEW THE MAINTENANCE TRAINING CURRICULA FOR MECHANICS AND INSPECTORS TO ENSURE THAT ALL CRITICAL AIRLINE MAINTENANCE POLICIES AND PROCEDURES ARE ADDRESSED DURING INITIAL AND RECURRENT TRAINING, AND IN CASES IN WHICH THEY ARE FOUND DEFICIENT, INCORPORATE SUCH MAINTENANCE POLICIES AND PROCEDURES IN THE CURRICULA. (Closed - Acceptable Action) |
Issued: 11-JAN-1995 | To: Northwest Airlines | A-94-226 |
REVIEW THE TRAINING RECORDS OF PERSONNEL ENGAGED IN THE MAINTENANCE AND INSPECTION OF AIR CARRIER AIRCRAFT TO ENSURE THAT SUCH PERSONNEL HAVE RECEIVED THE FORMAL TRAINING REQUIRED UNDER 14 CODE OF FEDERAL REGULATIONS 121.375. (Closed - Acceptable Action) |
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Fotos

accident date:
01-03-1994type: Boeing 747-251B
registration: N637US

accident date:
01-03-1994type: Boeing 747-251B
registration: N637US

accident date:
01-03-1994type: Boeing 747-251B
registration: N637US
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 Hong Kong-Kai Tak International Airport to Tokyo-Narita Airport as the crow flies is 2920 km (1825 miles).
Accident location: Exact; deduced from 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.
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