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Cases › DCA17FA076 · Part 121 airline · Class 1

MCDONNELL DOUGLAS MD80Ameristar Air Cargo, Inc.

Ypsilanti, MI, USA · 2017-03-08·N786TW

0
fatal
0
serious
Minor injury
highest injury
Substantial
damage
Replay the flight data7,085 samples · 37 parameters14:49:43.0 – 14:52:24.0Replay the flight data53,544 samples · 17 parametersSRN 178,060 – SRN 179,925Replay the flight data247,807 samples · 37 parameters47:59:52.0 – SRN 178,424Read the cockpit voice recorder800 lines12:50:06 – 14:53:47AnalyseThe analystOne timeline · precedents · ask the docket · what the record saysGenerateInvestigation briefFacts, cause, recorder extremes, sequence, sourcesSourceNTSB docket60 documents on data.ntsb.gov

What happened

NTSB summary, verbatim

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/01.   On March 8, 2017, about 1452 eastern standard time, Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, a Boeing MD-83 airplane, N786TW, overran the departure end of runway 23L at Willow Run Airport, Ypsilanti, Michigan, after the captain executed a rejected takeoff. The 110 passengers and 6 flight crewmembers (two airline transport pilots and four flight attendants) evacuated the airplane via emergency escape slides. One passenger received a minor injury, and the airplane sustained substantial damage. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 121 as an on-demand charter flight and was destined for Washington Dulles International Airport, Dulles, Virginia. Visual flight rules conditions prevailed at YIP at the time of the accident.

Photographs

4the aircraft, and what the investigators found
Wreckage and site documentation · 4 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 jammed condition of the airplane's right elevator, which resulted from exposure to localized, dynamic wind while the airplane was parked and rendered the airplane unable to rotate during takeoff. Contributing to the accident were (1) the effect of a large structure on the gusting surface wind at the airplane's parked location, which led to turbulent gust loads on the right elevator sufficient to jam it, even though the horizontal surface wind speed was below the certification design limit and maintenance inspection criteria for the airplane, and (2) the lack of a means to enable the flight crew to detect a jammed elevator during preflight checks for the Boeing MD-83 airplane. Contributing to the survivability of the accident was the captain's timely and appropriate decision to reject the takeoff, the check airman's disciplined adherence to standard operating procedures after the captain called for the rejected takeoff, and the dimensionally compliant runway safety area where the overrun occurred.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Takeoff-rejected takeoff
    Flight control sys malf/fail
    defining event

Findings

3 causal · 2 contributing
  • CAUSE
    Aircraft › Aircraft systems › Flight control system › Elevator control system — Damaged/degraded
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Wind › High wind — Effect on equipment
  • CAUSE
    Environmental issues › Physical environment › Object/animal/substance › Residence/building — Effect on equipment
  • FACTOR
    Aircraft › Aircraft systems › Equipment/furnishings › Escape slide — Incorrect service/maintenance
  • FACTOR
    Environmental issues › Operating environment › Meteorological services — Accuracy of related info

Safety recommendations

6 issuedwhat changed because of this accident
  • A-19-001Closed - ReconsideredCLASS IIletter ↗

    TO THE BOEING COMPANY: Complete the development of a modification for Boeing DC-9/MD-80 series and 717 model airplanes that will prevent the possibility of elevator jamming due to ground wind exposure.

  • A-19-002Closed - Acceptable ActionCLASS IIletter ↗

    TO THE BOEING COMPANY: Develop new preflight procedures or other mitigations for Boeing DC-9/MD-80 series and 717 model airplanes that will enable a flight crew to verify before takeoff that the elevators are not jammed.

  • A-19-003Closed - Acceptable ActionCLASS IIletter ↗

    TO THE BOEING COMPANY: Until the actions in Safety Recommendations A-19-1 and -2 are completed, revise the Aircraft Operating Manual and Aircraft Maintenance Manual for Boeing DC-9/MD-80 series and 717 model airplanes to lower the ground gust criteria that will require physical inspections and operational checks of the elevators by maintenance personnel.

  • A-19-004Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Determine if the ground gust limit loads contained in Title 14 Code of Federal Regulations 25.415 adequately ensure that critical flight control systems are protected from hazards introduced by ground gusts that contain dynamic, vertical wind components.

  • A-19-005Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Ensure the operators of Boeing DC-9/MD-80 series and 717 model airplanes have procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the Aircraft Maintenance Manual.

  • A-19-006Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Revise Order JO 7900.5D, Surface Weather Observing, Change 1, to specify sign-off procedures and backup augmentation responsibilities for all types of weather-observing personnel when they are unable to perform their prescribed duties from their normal duty station during normal duty hours.

Sequence of events

14 timed eventsfrom the FDR factual report · claude-sonnet-5
  1. 01:04 EST (178,423 SRN)Post-landing/taxip.4
    FDR stopped recording after previous landing (parking brake applied)
  2. 01:25 EST (178,432 SRN)Post-landing/taxip.3
    FDR started recording
  3. 01:33 EST (178,933 SRN)Post-landing/taxip.3
    FDR stopped recording
  4. 07:10 EST (178,940 SRN)Groundp.3
    FDR started recording
  5. 07:12 EST (179,059 SRN)Groundp.3
    FDR stopped recording
  6. 12:36 EST (179,068 SRN)Groundp.3
    FDR started recording
  7. 12:37 EST (179,129 SRN)Groundp.3
    FDR stopped recording
  8. 12:42 EST (179,140 SRN)Groundp.3
    FDR started recording
  9. 12:49 EST (179,569 SRN)Groundp.3
    FDR stopped recording
  10. 14:35 EST (179,580 SRN)Groundp.3
    FDR started recording
  11. 14:38 EST (179,755 SRN)Groundp.3
    FDR stopped recording
  12. 14:49 EST (179,764 SRN)Pre-takeoffp.3
    FDR started recording (last time before rejected takeoff)
  13. 14:49:43 ESTTaxip.4
    Aircraft began taxiing to the departure runway
  14. 14:52 EST (179,924 SRN)Takeoff/Rejected takeoffp.3
    End of FDR recording (rejected takeoff, runway excursion)

NTSB analysis

from the final report

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/01.   On March 8, 2017, about 1452 eastern standard time, Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, a Boeing MD-83 airplane, N786TW, overran the departure end of runway 23L at Willow Run Airport, Ypsilanti, Michigan, after the captain executed a rejected takeoff. The 110 passengers and 6 flight crewmembers (two airline transport pilots and four flight attendants) evacuated the airplane via emergency escape slides. One passenger received a minor injury, and the airplane sustained substantial damage. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 121 as an on-demand charter flight and was destined for Washington Dulles International Airport, Dulles, Virginia. Visual flight rules conditions prevailed at YIP at the time of the accident.