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    Northwest Flight 255 Report

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    60K views140 pages

    Northwest Flight 255 Report

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    WXYZ-TV Channel 7 Detroit
    Northwest Flight 255 Report

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    PB88-910406 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT NORTHWEST AIRLINES, INC. McDONNELL DOUGLAS DC-9-82, N312RC DETROIT METROPOLITAN WAYNE COUNTY AIRPORT ROMULUS, MICHIGAN AUGUST 16, 1987 NTSB/AAR-88/05 UNITED STATES GOVERNMENT ‘THESE CORRECTIONS SHOULD BE MADE TO THE PREVIOUSLY PUBLISHED REPORT IDENTIFIED AS FOLLOWS [AIRCRAFT ACCIDENT REPORT NORTHWEST AIRUNES, INC. McDONNELI, DOUGLAS DC-5-82, NS12RC DETROIT METROPOLITAN WAYNE COUNTY AIRPORT ROMULUS, MICHIGAN ‘AUGUST 16,1987 NTSB/AAR-B8/05 (pB88-910406) 1, The lasttine cn the bottom of page 28 should read: 2 throttle split of about 2/3 of a throttle knob diameter. The measurements obtained were slightly {ess than half of the available tnrottle lever movement. The No, 2 engine wes started to obtain a 2. Add ve following finding to the bottom of page 67: 12, The loss of input from the airplane to the CAWS unit does not illuminate the CAWS fai ight TECHNICAL REPORT DOCUMENTATION PAGE 1. Report No. . Government Accession No. 3. Recipient's Catalog No. NTSB/AAR- 88/05 PBBBs10005 4, Title and Subtitle: Aircraft Accident Report-Northwest | 5. Report Date Airlines, ne., McDonnell Douglas DC-S-2, N3I2KC, Dewoit May 10, 1988 Metropolitan Wayne County Airport, Romulus, Michigass, | f= auguet 16, 1987 6. Terforming Organization = Code 7. Authors) ee [8 Perfonning Organization Report No. 9. Performing Organization Kame and Adaress 10. Work Unit. ane National Transportation Safety Board nnn Bureau of Accident Investigation 11, Contract or Grant No, Washington, D.C. 20594 a ra lashington, 5 13. Type of Report and Period Covered 12. Sponsoring Agency Name and Address nicopt pecans Neeost| “August 16, 1987 NATIONAL TRANSPORTATION SAFETY BOARD SS See SREP RTT Washington, 0.C. 20594 ‘Sponsoring Agency Code 15. Supplementary Notes 16. Abstract About 2046 eastern daylight time on 285 crashet! shorly after taking off from runway 3 center at the Detroit Metropolitan Wayne County Airport, Romulus, Michigan. Flight 255, a McDonnell Douglas OC-9-82, US, Registry N3I2RC, was a regularly scheduled passenger flight and was en route to Phoenix, Arizona, According to witnesses, flight 255 began its takeoff rotation about 1,200 to 1,500 feet from the: fend of the runway and lifted off near the endl of the runway. After litolf, the wings of the airplane rolled to the left and the right about 35° in each direction. The airplane collided with ‘obstacles northeast of the runway when the left wing struck alight pole located 2,760 feet beyond ‘the end of the runway. Thereafter the airplane struck other light poles, the roof of a rental car facility, and then the ground. 1 continued to slide along a path aligned generally with the extended centerline of the takec.( cunway. The airplane broke up as it slid across the ground and postimpact fires erupted alony the wreckage path. Three occupied vehicles ona road adjacent to Key Words 18. Oistibution statement Thisdocument isavailable to the public through the National Technical lnlarmation Service Soringfield, Virginia 22161 Security a |” Security Gassiation 21. No von Price airplane configuration; flaps and slats retraction; central ‘aural warning system; supplemental stall recognition ‘systems; circuit brea‘; lightcrew standardization, cockpit dscialine (of this report) (of thispage) UNCLASSIFIED. UNCLASSIFIED 1765.2 (Rev. 3/88) ‘CONTENTS EXECUTIVE SUMMARY FACTUALINFORMATION History ofthe Flight Injuries to Persons Damage to the Airplane Other Damage Personnel information Airplane information ‘Weight and Balance Flap and Slat Systems Takeoff Condition Computer The Digital Flight Guidance System Stall Protection System Central Aural Warning System CCAWS Unit Self-Monitor system Meteorologicat information ‘Navigational Aids ‘Communications ‘Aerodrome information Flight Recorders ‘The Cockpit Voice Recorder The Digital Flight Data Recorder ‘Wreckage and Impact information Medical and Pathological information Fire Survival Aspects Crash, Fire, Rescue Disaster Plans Testsand Research The CAWS Unit ‘CAWS Sound Spectrum Analysis Electronic Equipment Cockpit Wiring and Circuit Breakers Flap Handie Module Airplane Performance Other information Northwest Airlines and Republic Airlines Merger Proficiency Teaining The 0C-9-82 Checklist Checklist Procedures Human Performance Research Projects FAA Surveillance Useful or Effective investigative Techniques ANALYSIS: General The Accident The DFDR Readout and Airplane Performance Study ‘The Physical Evidence The Central Aural Warning System Flighterew Checklist Performance Training ‘Automated Systems Use Flightcrew Acti The Captain's He CONCLUSIONS Fingings Probable couse RECOMMENDATIONS: GLOSSARY AAPPENDIKES “Appendix A~'~restigation and Hearing ‘Appendix.--Personnel information “Appendix @-CVR Transcript ‘Appendix D-Viual Displays of light 255 ‘Appendix F--DC-9-82 Checklist 7 aN ae EXECUTIVE SUMMARY About 2046 eastern daylight time on August :6, 1987, Northwest Airlines, Inc, flight 255 crashed shortly after taking off from runway 3 center at the Detroit Metropolitan Wayne County Airport, Romulus, Michigan, Flight 255, @ McDonnell Douglas DC-9-82, U.S, Registry N312RC, was a regularly scheduled pastenger flight and was en route to Phoenix, Arizona, with 149 passengers and 6 crewmembers According te witnesses, flight 255 began its takeoff rotation about 1,200 to 1,500 feet from the ‘end of the runway and lfted off near the end of the runway. After liftoff, the wings of the airplane rolled to the left and the right about 35° in each direction. The aitplane collided with obstacles ‘northeast of the runway when the left wing struck alight pole located 2,760 feet beyond the end of the runway. Thereafter the airplane struck other light poles, the roof of a rental car facility, and thon the ground, it continued to slide along a path aligned generally with the extended centerice of the takeoff runway. The airplane broke up as it slid across the ground and postimpact fires ‘erupted slong the wreckage path. Three occupied vehicles on a road adjacent to the airport and ‘numerous vacant vehicles in a rental car parking lot along the airplane's path were destroyed by impact forces andlor fire. ‘0f the persons on board flight 255, 148 passengers and 6 crewmembers were killed; 1 passenger, 2 d-year-old child, was injured “eriously. On the ground, two persons vere killed, one person wat injured seriously, nd four persons suffered minor injuries. ‘The National Transportation Safety Board determines that the probable cause of the accident ‘was the flightcrew's failure to use the taxi checklist to ensure that the flaps and slats were extended for takeoff. Contributing to the accident was the absence of electrical power to the airplane tokeotf warning system which thus did not warn the flightcrew that the airplane was not configured properly for takeoff. The reason for the absence of electrical power could not be davermined, NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT NORTHWEST AIRLINES, IN McDONNELL DOUGLAS DC-9-82, N312RC DETROIT METROPOLITAN WAYNE COUNTY AIRPORT, ROMULUS, MICHIGAN ‘AUGUST 16, 1987 1, FACTUALINFORMATION 1.4 History ofthe Fight ‘On August 16, 1987, a Northwest Aitlines (Northwest flighterew picked up a McDonell Douglas 0¢-9-82 airplane, N312RC, at Minneapolis, Minnesota, ana operating as Hight 750, flew the airplane to Saginaw, Michigan, with an en route stop at Detroit Metropolitan Wayne County Airport (Detroit-Metro), Romulus, Michigan, arriving at Saginaw about 1840 eastern daylight time. At Saginaw N312RC became flight 255 and was flown by the same flightcrew which had brought the airplane in. Fligh 1255, was.a regularly scheduled passenger flight between Saginaw and Santa Ana, California, with en route stops at Detroit and Phoenix, Arizona. The rligiht was to be conducted in ‘accordance with the provisions of 14 Code of Federal Regulations (CFR) Parts 91 and 121. About 1853, flight 255 departed Saginaw and about 1942 arrived at its gate at Detroit: Metro. Except for taxiing past and having to make a 180" turn to return to its assigned arrival gate, the flight to Detroit was uneventful After the disembarking passengers had left the airplane, a Northwest mechanic entered the cockpit and reviewad the airplane and cabin maintenance logbooks. He stated that no discrepancies were entored in either logbook. There was no record of any maintenance having been performed on the airplane while it was ot Detroit-Metro About 10 to 5 minutes before the flight was due to depart the gate, a company transportation agent brought the flight release package to the airplane. He was met by the first officer who told him that the captain was not on board. The first officer inspected the package ‘which contained the dispatch documents, signed the release, and returned the signed copy to the agent. As the agent left tne airplane, he met the captain who had been conducting 9 walkaround inspection of the alplane and showed him the signed copy of zhe flight release. The captain studied the release, told the agent that it was allright, and thanked hirs, ‘About 2029, the final weight tabulation (weight tab) was delivered to the flighterow. light 255 deporced the gate with 149 passengers and 6 crewmembers on board. Flight, 255 was pushed back to spo: four. 1/ (See figure 1.) During the pushback, the flightcrew ‘accomplished the BEFORE (engine) START portion of the airplane checkiist, and, at 2033:08, they began starting the engines potlocsted onthe outer amp neo! tony Mie. ‘At 203440, after the engines had been started, the ground crew disconnected the tow bar from the airplane, and, at 2034:50, the west ground controller cleared the flight to "taxi via the ramp, hold short of (tariway) delta and expect runway three center (3C} (for takeoff)..." The conteoller also informed the flightcrew that Autoniatic Terminal Information Service (ATIS) Hotel (4) was now current and asked them if they had the information. The flightcrew repeated the taxi instructions and stated that they had the ATIS information. At 2035:43, the ground controller cleared flight 255 to continue taxiing, to exit the ramp at taxiway charlie (C), to tax! to runway 7 ‘and to change radio frequencies and then contact the ground controller on 119.85 Mhz. At 2035:/ the first officer repeated the taxi clearance, but he did not repeat the new radio frequency nor wi hho tune the radio to the new frequency. Thereafter, the first officer told the captain, “Charlie for ‘three center, right." ATIS "lH had been transcribed at 2028:35 and was being broadcast at the time of the accident. Examination ofthe cockpit voice recorder {CV) recording showed that the flightcre w had not received information "H" before they began to taxi. However, at 2035:18, infermation "H™ began on the first office’ radio channel, and, at 2035:55, he told the captain that ne was leaving the airplane's No.1 radio "to get the new ATIS.” About 2025, the tower supervisor began coordination to change Detioit-Metro from runway 21 configuration to a runway 3 configuration. The change was completed at 2028. ATIS. H' ‘was the first ATIS transcription to contain and broadcast this information. It also described the Calling and visibility and stated in part that the temperature was 8F F, that the wind was 300" at 17knots, and that”... ILS approaches are in use to runways three left (31) and three right (3R) departing runways three... low level windshear advisories arein effect ‘The takeoff performance data in the flightcrew's dispatch package was based an using ithar runways 21 or 21R; however, the flight had been instructed by the ground controller to taxi ‘0 runway 3C, the shortest of the three available runways. The final takeoff weight for the airplane ‘was 144,047 pounds. At 2037:08, the captain asked the first officer if they could use runway 3¢ for takeoff. Because of the runway change, the first officer had to refer to the company’s Runway Takeoff Weight Chart Manual to verify that their takeolf weight was below the allowable limits for runway 3C. The takeoff weight chart showed that withthe flaps set at 11°, the maximum allowable ‘takeoff weights for runway 3C at 85" F and 99° F were 147,500 pounds and 145,100 pounds, respectively. After consulting the manual, the first officer told the captain runway 3C could be used for takeoff and the captain concurred withthe first officer's evaluation. During the taxi out, the captain miss2d the turnoff at taxiway C, When the firs officer contacted ground cantrol, the ground controller redirected them to taxi to runway 3C and again requested that they change radio frequencies to 119.45 Mhz. The fist officer repeated the new Frequency, changed over, and contacted the east ground convoller. The east ground controller gave the flight a new taxi route to runway 3C, told them that ATIS "H" was stil current, that windshear alerts were in effect, and that the altimeter setting was 29.85 inlg, The flighterew acknowledged receipt of the information ‘At 2082:11, the local controller cleared flight 255 to taxi into position on runway 3C ‘and to hold. He told the flight there would be a 3-minute delay in order to get the requiced "in-trail separation behind traffic ust departing.” At 204404, flight 285 was cleared for takeof! The CVR recording showed that engine power began increasing at 2044:21 that the flightcrew could not engage the autothrottle system at frst, out, at 2044:38, they did engage the system, and that the first officer called 100 knots at 2084:45,6. sMt 2044:57.7, the first officer called "Rotate," and, at 2045:08.1, the stall warning stick shaker activated and continued operating until the CVR recording ended. At 2045:08.1, 2045:11.4, 2085: 14.3, and, 2045.17.1, the aural tone and voice warnings of the supplemental stall recognition system (SSRS) also activated. Between 2044:01 and 2045:05.6, the CVR recording did aot contain any sound of the takeoff warning system Indicating that the airplane was not configured properly for takeott Witnesses generally agreed that flight 255's takeoff rll was longer than that normally made by similar airplanes. They staved that the flight began its rotation about 1,200 to 1,500 feet from the departure end of the runway, agreed that i rotated to a higher pitch angle than other 10C-9s, and agreed that the al ofthe airplane came close to striking the runway Only a few witnesses recalled any details about the position of the airplane's leading ‘edge wing slats, trailing edge wing flaps, or fanding gear. Most of these witnesses said that the landing gear was retracted after liftoff. Two Northwest frst officers recalled thatthe flaps and slats, were extended. One first officer was in the airplane directly behind flight 255 in the takeoff Sequence. According to her, “the flaps were extended, which is normal, but | could not. .. state the actual degree of flap extension.” She did not describe the position of the slats. The second first. officer's airplane was parked on taxlway "A" between the ramp and taxiway "J." The airplane was facing runway 3C and about 150 feet from it, (See figure 1) He testified that he observed the flaps and slats as flight 255 rolled past hie airplane and, “The slats and flaps were extended.” However, he ‘was unable toestimate their degree of extension. After fight 255 became airborne it began rolling to the left and right. Witnessas ‘estimated that the bank angles during the rolls varied from 15° to 90". Some witnestes stated that the airplane wings leveled briefly and then banked to the left just before the ieft wing hit a light pole in arental car lot. Most witnesses did not see fire on the airplane untl it was ovo: the rental car lot. The first officer of the Northwest airplane parked on taxiway "A" testified that f:qht 255 was intact until the feft wing struck the light pole in the auto rental car lot. After tne yzirg struck the pole, he saw what appeared to be "a four- to five-foot chunk of the wing section..." fal from the airplane, He did not see any fire on the airplane unti) after it struck the light pole and then he saw an orange flame..." emanating from the leit wing tip section, ‘After impacting the light pole, flight 255 continued to roll to the left, continued across the carlo, struck a light pole in a second rental car lot, and struck the side wall of the roof of the auto rental facility in the second rental car lot. Witnesses stated that the airplane was ir a 90" teft- wing-down attitude when it struck the coof and that it continued rolling and was still re ing to the Teft tien itimpacted the ground on a ead outside the airport boundary. The airplane continued to side along the road, struck a railroad embankment, and disintegrated as it slid along the ground. Fires erupted in airplane components scattered along the wreckage path. Three occupied vehicles fen the oad and numerous vacant vehicles in the auto rental parking lot along the airplane's path ‘were destroyed hy impact forces and or fire On board flight 255, 148 passengers and 6 crewmembers were killed; 1 passenger, a 4. year-old child was injured seriously. On the ground, two persons were killed, 1 person was injured setiously, and 4 persons suffered minor injuries, The coordinates of the accident were 42°14" latiude and 83°20’ Wlongitude. Injuries to Persons See able 1 Damage io the Airplane ‘The 66:9-82 was destroyed by ground impact and postimpact fi October 1987 Worldwide Aviation and Merkering Service (AVMARK) Newsletter, the price of & 1DC-9-82 varied between ebout $20.5 million and $21.5 milion depending on how it was equipped 14 Other Damage ‘The front and rear walls above the roof of the auto rental facility were damaged by impact forces and firs; the roof was damaged by fie. Three light standards in the rental car tots ‘were damaged by impact forces. Numerous unoccupied automobiles in the rental car parking fot ‘were damaged or destroyed by either ‘mpact forces, fire, or both. Two automobiles and a GMC truck located on the road outside the airport boundary were destroyed by either impact forces, fire, or both, 1s Personnel information The flighterew and cabin crew of flight 255 were qualified in accordance with applicable Federal and Northwest regulaiions and procedures. (See appendix B.) Examination of the flightcrew's training records uid not revea! anything unusual. In addition, the investigation of the flightcrew's personal Lackground and actions during the 2 to 3 days before the uccident fight did ‘ot reveal anytiting remarkable. ‘The Captain- The 57-year-old captain was hired originally by West Coast Airlines on October 3, 1985. In 1960, as a result of two mergers, West Coast evolved into Republic Airlines. On January 23, 1986, Northwest Airlines bought Resublic Airlines and the combined companies we renamed Northwest Aicines inc. The captain remained employed continuously by the companies ‘throughout tive transactions. During his 31 years with these companies, the captain was type rated (on seven different airplanes ranging from the McDonnell Douglas DC-3 to the Boeing 757 (2-757) He also served as a Federal Aviation Administration (FAA) designated check airman in the 8-727 (September 1978-July 1979) and the DC-9 and DC-$-82 (September 1979-April 1964) airplanes. ‘The captain upgraded initially to captain in December 1972. Except for one 17-month peried during 1978-79 and one of about 4 months during 1985 while serving as captain on Boeing 727 (8-727), the captain had flown airplanes with s two-pilot crew. (See appendix 8.) ‘The captain had upgraded 10 ceptain on the 8-757 in February 1986. However, afer the merger, Northwest disposed of the six B-757s which had been operated by Republic, The isposal of these airplanes required the captain to return to the DC-4-2. 2/ The captain requalitied {a captain in the DC- 9-82 in May 1987. Northwast pilots are not cross utilized in the DES-B2 end. 9 series avplane:. Since May 1987, the captain had been assigned to and had flown only the DC-9-82 Virtually 21 of the irterviewed first officers and other captains who had flown with the captain described him as 2 competent and capable pilot. They stated that the captain slwovs uted the cirplane checklist. Ore first officer stated that the captain had a reputation "asa strict, By-the book pilot who would not toler te eny deviation from standard procedures.” Three of the captain's present or former supervisors stated thet they had never had {any professional or personal problems wath him. ‘The Fist Ofer, The 35-year-old first cfficer was hired by North Central Airlines in fay 1979. Republic Airlines resulted from 2 merger of North Certral and Southern airlines. The first officer nas been employed continuously by North Central, Republic, and Northwest Airlines since his date of hira With the exception of one training repon during his early probationary perind with the airine, ail of the raptains with whom the first officer had flown graded his performance as average or above average. Commenis contzined in some of his grade sheets dezcribea him 3s follows: “competent pilot,” "easy to work with," "goad in all respects,” and "very personable, thereugh job..." ‘One captain with whom the first officer recently had flown stated, thax he appeared to bbe a good pilot. Although he did not remember ifthe first officer had initiated checklists, re stated that the first cfficer did not appear te be a "yas man" and that he remembered the fi ‘handling a very busy period “vary well and callng a potesitial problen: [to his} attention. ‘capusing who recenily had flown with the first olficer described his ability favorable terms, The “st officer's supervisors stated that they hed not hed any personal or professional problems:with him, The Northwest recors showed that the captain and first officer had flown together on ‘Assgust 7-10 and 14-15, 1987. During thi: 6-day period they had flown iB trip legs. 16 Airplane information ‘the 0¢-9-82, US. Registration N312RC, was manufortued: on October 15, i981; it was dalivered to Republic Airlines on December 8, 1982. Since delivery, W312RC has been opzrated by Republic Airlines ang, after its purchase of Republic, by Northwest Airlines, inc ‘The airplane was powered by two Pratt and Whitney Model JT8D-217 turbofan jnes. The JTUD-217 engine has 2 normal and maximum sea level static thrust ratings of 20,000 pounds and 20,850 pounds at 84" F and 77*F, respectively; these ratings ae limited to $ minutes, FT TADETAT Te darn oT he McDonnell Dovgis C540 sara apne, The niplane walsoraerred tas MO-80 01 Mo-a, The dexriton 069-82 wis be wad herein nie reterenced publeation, document, oF quot spac another nama, inwhichcae ther Examination of the airplane flight end maintenance logbooks did not reveal any discrepancies or malfunctions that would have contributed to the accident. In additien, the examination ditciosed that, atthe time of the accident, there ware no discrepancies er malfunctions lin the toghaoks involving minimum equipment ist (#481) items. 3 16.4 Weight and Balance According to the Northwest DC-9-82 Airplane Pilots Handbook (APH), the maximurn certificated takeoff weight of the airplane is 149,500 pounds. The airplane is lisited to a maximurn tallwind o° 10 knots for takeoff and landing and a maximum demonstrated crosswind oF 30 knots for takeoff and landing. The actual airplane weight for the takeoff at Detroit Metro was 148,087 pounds, its computed center of gravity (c.q.) fr the ensuing takeoff was 9.8 percent of the mean aerodynamic chord (MAC) of the wings and was within the forward and aft ca, limits of 3.1 poreentand 28.4 percent MAC, respectively. ‘The CVR showed that the latest runway temperature information known to the flighterew was the 88°F reading contained in ATIS "H."_ The CVR also showed that the flightcrew planned to use 11° fiaps for the takeoff. Based on the 88°F embient temperature, flaps al 11", and the siats at the takeoff or mic-sealed position, the company’s takeoft weight chart showed that the maximum sllowable takeoff weight for runway 3C was 146,060 pounds and that reduced engine thrust could not be used for takeoff. The required engine pressure rat (EPR) for the ensuing ‘takeo'f would have been 1.95. The takeoff weight charts provided weight corrections based on, hhesdwind or tilwind components. On runway 3C, the maximum allowable weights either could be inereased by 230 pounds for each knot of headwind or had to be decreased by 960 pounds for each knot of talwind. 182 Flap and Slat Systems The tailing edge flaps and leading edge slats are extended and retracted by the flapisiat handle (flap handle) located on the right side of the control oedestal The wing tailing edge flap system consists of an inboard and outboard flap segment ‘on each wing. Each flap segmer tis powered by an inboard ana outboard hydraulic cylinder on each wing. The outboard cylinders are operated by the left hydraulic system; the inboard cinders are ‘operated by the right hydeaulic system. Although the flaps normally operate on pressure from both ‘hydraulic systems, they will operate on a single system at a reduced rate. All lap segments ae linked ‘together mechanically to provide synchronization during extension and retraction, Six fixed position detents are located along the left side of the flap handle, track, oF race: UP/RET, 0°, 11%, 15%, 28", and €U", When the flap handle is positioned in any of the detents, a pin (on the left side of the handle drops into the deten and keeps the handle at the selected position ‘while the flaps move to the. commat-4ed position. To move the flap handle from, for example, the 11° detent to the UPIRET detent, a spring-loaded lever, or trigger, on the left side of the handle must be raised to release the pin from the detent, As the lever is moved forward, the trigger must be hid in the raised position until the flap handle has cleared the 0" detent. After passing the detent, the trigger must be depressed to transit the slat retract gate and reach the UP/RET detent.

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