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Cases › DCA11FA050 · Part 121 airline

BOEING 737-823American Airlines

Los Angeles, CA, USA · 2011-01-03·N831NN

0
fatal
0
serious
No injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

The crew reported that preflight preparation was normal, with the departure runway and takeoff data automatically uploaded to the airplane Flight Management Computer (FMC) via ACARS (Airborne Crew Addressing and Reporting System). Shortly before leaving the gate, Air Traffic Control (ATC) informed the crew that the departure runway was changed to runway 7L. According to American Airlines, on the B737-800, only the first four runways listed on the Takeoff Performance System (TPS) can be auto-loaded if a runway change occurs after the initial upload. Runway 7L was not one of the first four runways listed on the TPS, so the First Officer (FO) manually input the data, including the prescribed V-speeds using information on the preflight paperwork. Flight planning data indicated that the conditions at the time of the accident called for a flaps 1 takeoff with V1 (takeoff decision speed) of 153 knots, a Vr (rotation speed) also of 153 knots, and V2 (scheduled takeoff speed) of 158 knots. The recorded data indicates the manually entered V speeds in the FMC were V1 of 123 knots, Vr of 153 knots and V2 of 158 knots. FMC data was not recovered, but the most likely reason for the inappropriate V1 value was determined to be a keystroke entry error by the FO when manually entering data. During the takeoff roll, the Captain reported hearing the automatic, aircraft-generated V1 callout occur, and he began to rotate the airplane. Recorded data is consistent with rotation beginning as the airplane was passing through 123 knots, approximately 30 knots below the proper rotation speed. The airplane pitched up to about 11 degrees just prior to liftoff at 148 knots. The airplane operating manual specifies that tail contact will occur at 11 degrees of pitch if still on or near the ground. The manual also states that “Early, rapid or over-rotation may result in a tailstrike.” Although there was no mention of a "Vr" callout, V1 and Vr are typically close in value for a 737, so the Captain may have reacted to the erroneous V1 callout, expecting that the airplane was also at Vr. Had the Captain waited for a “Vr” callout by the FO, the erroneous V1 entry would have had no effect. Post event examination revealed that the airplane experienced substantial damage to the lower rear fuselage.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
5-5-11 N831NN MEX (27721893559)
Pete Macklin · CC BY-SA 2.0 · Wikimedia Commons

Probable cause

the Board's determination
the early rotation of the airplane to an angle at which the fuselage contacted the runway. Contributing to early rotation was the Captain’s reaction to the erroneous V1 automated callout, likely assuming that the airplane was at or close to the correct Vr at the same time. The erroneous automated callout was likely due to a keystroke entry error by the FO when manually entering takeoff data for a newly assigned departure runway.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Takeoff
    Tailstrike
    defining event

Findings

3 causal · 0 contributing
  • CAUSE
    Personnel issues › Action/decision › Action › Incorrect action sequence — Pilot
  • CAUSE
    Personnel issues › Action/decision › Info processing/decision › Expectation/assumption — Pilot
  • CAUSE
    Personnel issues › Action/decision › Action › Incorrect action performance — Copilot

Sequence of events

7 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)
  1. 10:40:49 PSTtakeoffp.3
    FMC V2 speed 158 knots
  2. 10:40:53 PSTtakeoffp.3
    FMC Vr speed 153 knots
  3. 10:40:57 PSTtakeoffp.3
    FMC V1 speed 123 knots
  4. 10:41:14 PSTrotationp.3
    Nose gear weight-on-wheels transitioned from ground to air
  5. 10:41:26 PSTlift-offp.3
    Maximum recorded pitch 15.3 degrees; maximum vertical acceleration around this time 1.13 g to 1.11 g (tail strike)
  6. takeofftakeoffp.3
    Trailing edge flaps remained at 1 degree and slats 1 to 8 recorded mid-extended during the takeoff
  7. 10:33:50-11:04:50 PSTclimbp.2
    Climb to a pressure altitude of 33,365 ft over the 31-minute recording

NTSB analysis

from the final report

The crew reported that preflight preparation was normal, with the departure runway and takeoff data automatically uploaded to the airplane Flight Management Computer (FMC) via ACARS (Airborne Crew Addressing and Reporting System). Shortly before leaving the gate, Air Traffic Control (ATC) informed the crew that the departure runway was changed to runway 7L. According to American Airlines, on the B737-800, only the first four runways listed on the Takeoff Performance System (TPS) can be auto-loaded if a runway change occurs after the initial upload. Runway 7L was not one of the first four runways listed on the TPS, so the First Officer (FO) manually input the data, including the prescribed V-speeds using information on the preflight paperwork. Flight planning data indicated that the conditions at the time of the accident called for a flaps 1 takeoff with V1 (takeoff decision speed) of 153 knots, a Vr (rotation speed) also of 153 knots, and V2 (scheduled takeoff speed) of 158 knots. The recorded data indicates the manually entered V speeds in the FMC were V1 of 123 knots, Vr of 153 knots and V2 of 158 knots. FMC data was not recovered, but the most likely reason for the inappropriate V1 value was determined to be a keystroke entry error by the FO when manually entering data. During the takeoff roll, the Captain reported hearing the automatic, aircraft-generated V1 callout occur, and he began to rotate the airplane. Recorded data is consistent with rotation beginning as the airplane was passing through 123 knots, approximately 30 knots below the proper rotation speed. The airplane pitched up to about 11 degrees just prior to liftoff at 148 knots. The airplane operating manual specifies that tail contact will occur at 11 degrees of pitch if still on or near the ground. The manual also states that “Early, rapid or over-rotation may result in a tailstrike.” Although there was no mention of a "Vr" callout, V1 and Vr are typically close in value for a 737, so the Captain may have reacted to the erroneous V1 callout, expecting that the airplane was also at Vr. Had the Captain waited for a “Vr” callout by the FO, the erroneous V1 entry would have had no effect. Post event examination revealed that the airplane experienced substantial damage to the lower rear fuselage.