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Cases › DCA12IA113 · Part 121 airline

BOEING 737-3H4SOUTHWEST AIRLINES CO

El Paso, TX, USA · 2012-07-27·N379SW

0
fatal
0
serious
No injury
highest injury
Minor
damage

What happened

NTSB summary, verbatim

The aircraft experienced a structural failure of the nose landing gear (NLG) actuator retract beam when the landing gear was selected down during approach. The flight crew heard a loud noise during gear actuation, performed a go-around, and then returned to land uneventfully. Examination of the aircraft revealed a fracture across the horizontal leg of the actuator retract beam that propagated into the radius of the vertical leg. The fracture surface features were consistent with overstress failure with no sign of fatigue. The NLG hydraulic line to the actuator was found ruptured with abrasion damage aligned coincident with the NLG tire. Disassembly of the actuator revealed the restrictor fitting was installed in the head end of the actuator and the union fitting was installed on the rod end cap although engineering documentation requires the restrictor fitting to be installed in the rod end cap and the union fitting to be installed in the head end. The union and restrictor are normally placed in the actuator prior to installing the actuator on the airplane. Hydraulic fluid leaking from the actuator through the ruptured line allowed air to fill the actuator cavity on the head end of the actuator while hydraulic system pressure remained on the rod end. When the landing gear was selected down, air in the actuator allowed the actuator piston to move rapidly toward the head end. Due to the union rather than the restrictor being installed on the piston end, higher than normal hydraulic flow was permitted in the rod end of the actuator increasing the rate of piston movement. When the piston reached the end of range of motion, the resulting force was transferred to the NLG retract actuator beam.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
N379SW (5130588461)
Eddie Maloney from North Las Vegas, USA · CC BY-SA 2.0 · Wikimedia Commons

Probable cause

the Board's determination
the rupture of the nose landing gear hydraulic line that resulted from abrasions due to contact with the nose landing gear tire. Contributing to the incident was the incorrect installation of union and restrictor on the actuator.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Approach
    Aircraft structural failure
    defining event
  2. 2 · Approach
    Miscellaneous/other

Findings

3 causal · 0 contributing
  • CAUSE
    Aircraft › Aircraft handling/service › Maintenance/inspections › Scheduled maint checks — Incorrect service/maintenance
  • CAUSE
    Aircraft › Fluids/misc hardware › Misc hardware › Hoses and tubes — Incorrect use/operation
  • CAUSE
    Aircraft › Fluids/misc hardware › Misc hardware › Hoses and tubes — Incorrect use/operation

Sequence of events

8 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)
  1. about 12:41 MDTtakeoffp.3
    Aircraft departed and climbed to flight level 370
  2. about 13:35 MDTdescentp.3
    Descent for El Paso began
  3. 14:00:39-14:00:45 MDTapproachp.3
    At 7,836 ft pressure altitude the landing gear transitioned from up and locked to down and locked (gear lock parameters sampled only once every 4 seconds); coincident with the last sample of nose gear up and locked, the master caution sampled one warning at 14:00:39
  4. after 14:00:45 MDTapproachp.3
    Aircraft descended to about 4,240 ft pressure altitude (about 600 ft radio altitude) heading east
  5. about 14:04:47 MDTgo-aroundp.3
    Aircraft began a climb to about 4,900 ft pressure altitude while turning right
  6. about 14:07:15 MDTapproachp.3
    Aircraft began to descend while turning right back toward an easterly heading
  7. about 14:08:33 MDTlandingp.3
    Vertical acceleration fluctuated between 1.24 g and 0.79 g in under one second
  8. 14:08:41 MDTlandingp.3
    Nose gear weight-on-wheels transitioned from air to ground, about 8 seconds after the acceleration fluctuation

NTSB analysis

from the final report

The aircraft experienced a structural failure of the nose landing gear (NLG) actuator retract beam when the landing gear was selected down during approach. The flight crew heard a loud noise during gear actuation, performed a go-around, and then returned to land uneventfully. Examination of the aircraft revealed a fracture across the horizontal leg of the actuator retract beam that propagated into the radius of the vertical leg. The fracture surface features were consistent with overstress failure with no sign of fatigue. The NLG hydraulic line to the actuator was found ruptured with abrasion damage aligned coincident with the NLG tire. Disassembly of the actuator revealed the restrictor fitting was installed in the head end of the actuator and the union fitting was installed on the rod end cap although engineering documentation requires the restrictor fitting to be installed in the rod end cap and the union fitting to be installed in the head end. The union and restrictor are normally placed in the actuator prior to installing the actuator on the airplane. Hydraulic fluid leaking from the actuator through the ruptured line allowed air to fill the actuator cavity on the head end of the actuator while hydraulic system pressure remained on the rod end. When the landing gear was selected down, air in the actuator allowed the actuator piston to move rapidly toward the head end. Due to the union rather than the restrictor being installed on the piston end, higher than normal hydraulic flow was permitted in the rod end of the actuator increasing the rate of piston movement. When the piston reached the end of range of motion, the resulting force was transferred to the NLG retract actuator beam.