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Cases › CHI01FA104 · Part 121 airline

Airbus Industrie A320-200

Detroit, MI, USA · 2001-03-17·N357NW

0
fatal
0
serious
Minor injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

The Airbus A320 contacted the runway and the terrain during takeoff on runway 3C (8,500 feet by 200 feet, wet) at the Detroit Metropolitan Wayne County Airport. An emergency evacuation was made during which time the emergency evacuation slide on the 2 left (2L) door failed to deploy. The captain reported that during the initial takeoff run, he held half forward pressure until reaching 80 knots. He reported that up to this point, everything was normal. He stated he released forward stick pressure by about 100 knots and the nose of the airplane began lifting off the ground with neutral stick, which was not normal. He reported he applied about half forward stick and the nose came back down. He reported that at 120 knots the nose again began to rise with one half to one quarter stick input. He then pushed the stick forward to the forward stop and the nose came up at a rapid rate. The captain reported that his attention was focused outside the airplane and he did not hear the first officer call V1. He reported that he felt the airplane was going to stall so he pulled the power off and aborted the takeoff. The captain stated that he was trained not to perform high-speed aborted takeoffs, but he felt the airplane would have been uncontrollable if the takeoff continued. The captain stated the thrust reversers were deployed and he initially thought there was enough runway remaining to stop. He assumed the autobrakes activated, but he pressed on the brakes anyway. He reported the airplane was not decelerating and it departed the end of the runway at a high speed. The captain reported that deceleration was rapid once the airplane departed the paved surface and the engines flamed out during the ground roll. Post accident inspection of the airplane revealed the horizontal stabilizer trim was set to negative 1.7 (units of trim), when it should have been set at positive 1.7. The first officer stated he set the trim while on the taxiway. The captain did not notice the improper trim setting during the cross check which was part of the taxi checklist. Further investigation revealed the operator procedures were to set the trim using units instead of percentage of mean aerodynamic chord as recommended by the manufacturer. In addition, it was discovered that the manner in which the units of trim were displayed on the trim control wheel, on the electronic centralized aircraft monitoring system (ECAM), and in the aircraft communications addressing and reporting system (ACARS) were not consistent. As a result the Safety Board issued Safety Recommendations A-02-06 and A-02-07. Post accident examination of the 2L slide/raft that did not deploy revealed an improper chamfer on the telescopic girt bar which attaches the slide/raft to the airplane structure. This allowed the slide/raft to detach from the airplane when the 2L door was opened. As a result the Safety Board issued Safety Recommendations A-01-27 and A-01-28. Being a fly-by wire airplane, the Airbus A320 has two sources of control lag in the pitch control. One is the latency between the pilot's input and the elevator movement through the elevator aileron control (ELAC) computer and the other is the rate limit of the elevator. Examination of the digital flight data recorded data for this accident revealed the pilot changed the pitch input faster than the elevator system would respond and saturation occurred in the rate at which the elevator surface could respond to the inputs. This resulted in pilot inducted oscillations (PIO) during the takeoff roll.

Photographs

9the aircraft, and what the investigators found
The aircraft before the accident
Airbus A320 N357NW approaching McCarran Airport Oct 2009 (3996817513)
Eddie Maloney from North Las Vegas, USA · CC BY-SA 2.0 · Wikimedia Commons
Wreckage and site documentation · 8 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The pilot induced oscillations and the delay in aborting the takeoff. Factors associated with the accident were the first officer used an improper trim setting and the captain did not identify and correct the setting during the taxi checklist, and the wet runway conditions.

Safety recommendations

4 issuedwhat changed because of this accident
  • A-01-027Closed - Acceptable Alternate ActionCLASS Iletter ↗

    THE NTSB RECOMMENDS THAT THE FAA: IMMEDIATELY ISSUE AN EMERGENCY AIRWORTHINESS DIRECTIVE TO REQUIRE OPERATORS OF OVERWATER-EQUIPPED AIRBUS INDUSTRIE A319, A320, AND A321 AIRPLANES WITH MANUALLY CHAMFERED GIRT BARS TO (1) ENSURE THAT THE DIMENSIONS OF THE TRIGGER LOCKING MECHANISM AND THE STATIONARY PORTION OF THE GIRT BARS CONFORM TO THE DESIGN SPECIFICATIONS; (2) PERFORM A RELIABLE FUNCTIONAL TEST TO DEMONSTRATE THE PROPER ENGAGEMENT OF MANUALLY CHAMFERED GIRT BARS UNDER REALISTIC DOOR OPENING CONDITIONS; AND (3) REPAIR OR REPLACE ANY GIRT BARS THAT DO NOT MEET THE DIMENSIONAL REQUIREMENTS OR DO NOT PASS THE FUNCTIONAL TEST, BEFORE THE AIRPLANES ARE RETURNED TO SERVICE. (URGENT)

  • A-01-028Closed - Acceptable Alternate ActionCLASS IIletter ↗

    THE NTSB RECOMMENDS THAT THE FAA: ISSUE AN AIRWORTHINESS DIRECTIVE TO REQUIRE OPERATORS OF OVERWATER-EQUIPPED AIRBUS INDUSTRIE A319, A320, AND A321 AIRPLANES WITH MACHINE-CHAMFERED GIRT BARS TO, BY THE NEXT SCHEDULED MAINTENANCE ACTIVITY, (1) ENSURE THAT THE DIMENSIONS OF THE TRIGGER LOCKING MECHANISM AND THE STATIONERY PORTION OF THE GIRT BARS CONFORM TO THE DESIGN SPECIFICATIONS; (2) PERFORM A RELIABLE FUNCTIONAL TEST TO DEMONSTRATE THE PROPER ENGAGEMENT OF THE GIRT BARS UNDER REALISTIC DOOR OPENING CONDITIONS; AND (3) REPAIR OR REPLACE ANY GIRT BARS THAT DO NOT MEET THE DIMENSIONAL REQUIREMENTS OR DO NOT PASS THE FUNCTIONAL TEST BEFORE THE AIRPLANES ARE RETURNED TO SERVICE.

  • A-02-006Closed - Acceptable Alternate ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require operators of Airbus Industrie A319, A320, and A321 airplanes to set and cross-check the trim using center of gravity trim values only.

  • A-02-007Closed - Acceptable Alternate ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require operators of Airbus Industrie A319, A320, and A321 airplanes to ensure that the electronic centralized aircraft monitoring display and the aircraft communication addressing and reporting system load data sheet are configured so that they display trimmable horizontal stabilizer trim unit information in a manner that is consistent with the display on the degree scale of the trim wheel indicator.

Sequence of events

1 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)
  1. takeoff roll (accident flight)takeoff/RTOp.3
    Plots of the rejected takeoff, tail strike and overrun, overlaid with CVR transcript excerpts; a plot of the takeoff prior to the accident flight is attached for comparison; no numeric values in the text

NTSB analysis

from the final report

The Airbus A320 contacted the runway and the terrain during takeoff on runway 3C (8,500 feet by 200 feet, wet) at the Detroit Metropolitan Wayne County Airport. An emergency evacuation was made during which time the emergency evacuation slide on the 2 left (2L) door failed to deploy. The captain reported that during the initial takeoff run, he held half forward pressure until reaching 80 knots. He reported that up to this point, everything was normal. He stated he released forward stick pressure by about 100 knots and the nose of the airplane began lifting off the ground with neutral stick, which was not normal. He reported he applied about half forward stick and the nose came back down. He reported that at 120 knots the nose again began to rise with one half to one quarter stick input. He then pushed the stick forward to the forward stop and the nose came up at a rapid rate. The captain reported that his attention was focused outside the airplane and he did not hear the first officer call V1. He reported that he felt the airplane was going to stall so he pulled the power off and aborted the takeoff. The captain stated that he was trained not to perform high-speed aborted takeoffs, but he felt the airplane would have been uncontrollable if the takeoff continued. The captain stated the thrust reversers were deployed and he initially thought there was enough runway remaining to stop. He assumed the autobrakes activated, but he pressed on the brakes anyway. He reported the airplane was not decelerating and it departed the end of the runway at a high speed. The captain reported that deceleration was rapid once the airplane departed the paved surface and the engines flamed out during the ground roll. Post accident inspection of the airplane revealed the horizontal stabilizer trim was set to negative 1.7 (units of trim), when it should have been set at positive 1.7. The first officer stated he set the trim while on the taxiway. The captain did not notice the improper trim setting during the cross check which was part of the taxi checklist. Further investigation revealed the operator procedures were to set the trim using units instead of percentage of mean aerodynamic chord as recommended by the manufacturer. In addition, it was discovered that the manner in which the units of trim were displayed on the trim control wheel, on the electronic centralized aircraft monitoring system (ECAM), and in the aircraft communications addressing and reporting system (ACARS) were not consistent. As a result the Safety Board issued Safety Recommendations A-02-06 and A-02-07. Post accident examination of the 2L slide/raft that did not deploy revealed an improper chamfer on the telescopic girt bar which attaches the slide/raft to the airplane structure. This allowed the slide/raft to detach from the airplane when the 2L door was opened. As a result the Safety Board issued Safety Recommendations A-01-27 and A-01-28. Being a fly-by wire airplane, the Airbus A320 has two sources of control lag in the pitch control. One is the latency between the pilot's input and the elevator movement through the elevator aileron control (ELAC) computer and the other is the rate limit of the elevator. Examination of the digital flight data recorded data for this accident revealed the pilot changed the pitch input faster than the elevator system would respond and saturation occurred in the rate at which the elevator surface could respond to the inputs. This resulted in pilot inducted oscillations (PIO) during the takeoff roll.