Aviation Accident Summaries

Aviation Accident Summary ANC99FA012

ANCHORAGE, AK, USA

Aircraft #1

HL741

Boeing 747-400

Aircraft #2

RA865

Ilyushin IL-62

Analysis

The Boeing 747-400 was taxiing to Gate N-6, after landing on runway 6R. The flight crew reported to the tower that braking action on the runway was poor. While taxiing to the parking ramp, the captain commented to the first officer that the airplane was skidding. As the airplane approached Gate N-6, ground personnel observed the airplane's nosewheels turn 90 degrees toward the gate, but the airplane continued straight ahead, skidding the nosewheels sideways. Ground personnel heard, and the Flight Data Recorder confirmed, an increase in engine power as the airplane continued past the gate. The airplane was then observed turning right, away from the terminal, and colliding with a parked IL-62M airplane. A cleaning person aboard the IL-62M received minor injuries when she was knocked down by the collision. The crew told the NTSB investigator-in-charge that they did not use brakes until attempting to turn away from the parked airplane. Ground witnesses described the taxi speed as "faster than normal." The maximum ground speed recorded by the on-board recorders was 16 knots. The company flight manual states, in part: "(1) Turning... 10 knots or below (5 knots if wet or slippery)." Snow contamination was recorded by the airport authority commencing 11 hours prior to the accident. The airport "Snow Removal Plan" denotes the lead-in lines to the terminal as a Priority 1-A area. Continuous snow removal operations were being conducted at the time of the accident, with all Priority 1 areas, and numerous Priority II areas being plowed and treated. The lead-in taxi lines to the terminal had been sanded five hours prior to the accident. The ramp area, and the lead-in taxi lines had not been plowed. One hour after the accident, about 2 inches of unbroken snow was on the ramp.

Factual Information

HISTORY OF FLIGHT On November 11, 1998, at 0133 Alaska standard time, a Boeing 747-400 airplane, HL7414, operated as Flight 221 by Asiana Airlines of Seoul, Korea, sustained substantial damage when it collided with an Ilyushin IL-62 airplane. Both flights were being conducted under 14 CFR Part 129 as foreign flag carriers operating in the United States. The Asiana flight was taxiing to parking after landing at the Anchorage International Airport, Anchorage, Alaska. The 18 crewmembers and 220 passengers on board the Boeing were not injured. The Ilyushin was parked at gate N-2, and was being operated by Aeroflot Russian Airlines as Flight 853. It was scheduled to depart for San Francisco, California, at 0230. The crew of 11, and one contract cleaner, were on board preparing for departure; the passengers for this flight had not yet boarded. The crew of the Ilyushin were not injured; the cleaner on board reported a sprained wrist. The Asiana flight had departed John F. Kennedy International Airport, New York, New York, at 1828 Alaska standard time, and the destination was Anchorage. Continuous snow removal operations for the runways were in effect at the airport, and light snow was falling. At the time of the collision, witnesses stated that between one and two inches of dry snow had accumulated on the ground. When the NTSB investigator-in-charge (IIC) arrived about 0230, he observed a uniform layer of about 2 inches of loose snow on the north ramp, with dry pavement underneath. The ground marshaller for the Asiana airplane told the NTSB IIC that as the airplane reached N-6, he observed the nosewheels turn left, but the airplane continued straight ahead, with the nosewheels sliding sideways. The marshaller stated: "I gave the emergency stop sign (crossed wands). The aircraft slowed and then I heard an increase in engine power, then a reduction in power, and then a bigger increase in power. The aircraft disappeared in a cloud of snow..." He saw the airplane continue past gate N-4, and begin a right turn, away from the gate area. He then heard the collision. The left, outboard, engine (number 1) of the Boeing struck the left wingtip of the Ilyushin, and then the left wingtip struck the vertical stabilizer of the Ilyushin. Several other witnesses who were positioned either on the N-6 jetway, or on the ground, described the Boeing 747 taxiing in faster than normal, observing the nosewheels turn and slide sideways, hearing an increase in engine noise, and seeing a snow cloud behind the Boeing 747 (statements attached). The lead mechanic for another airline, who was sitting in a ground vehicle at gate N-8, provided a written statement which said, in part: "I was waiting for the Asiana 747-400 to clear the gate area, which I also had full view of.... As the Asiana flight approached, I observed it execute a right turn at N8. It was passing me when I saw, and heard, surprisingly, the unmistakable sound of thrust being applied to its engines. Within 2-3 seconds, I, and my vehicle was engulfed in a massive snow "whiteout". The 747-400 completely disappeared into the cloud of snow.... I arrived on the scene exactly at the same time as the emergency people did.... I do not remember if the Asiana airplane had any of its engines running when I arrived but I don't believe it did. I don't remember being in any sort of jet blast and there certainly would have been that given where I was standing. One thing I do know, is that the Asiana 747 applied power as it taxied by me." The Asiana captain and first officer told the NTSB IIC during two separate interviews in the Asiana airport offices on November 11 (at 0300, and again at 1130), that when the captain turned the steering tiller to turn left into gate N-6, the airplane did not respond to tiller inputs, and that after passing gate N-4, they saw the Ilyushin in front of them at gate N-2. The captain stated that he applied right tiller, and right side brakes to turn to the right, away from the Ilyushin and the terminal, but was unable to miss striking the Ilyushin. The crew indicated they then shut down all four engines, and disembarked the passengers using a stair truck. During both interviews, and all subsequent interviews, an interpreter was provided by Asiana Airline. The captain told the NTSB IIC during the first interview on November 11, immediately after the accident that he did not use any reverse thrust, that he did not apply power, and that he kept the throttles at the idle position. He said he did not use differential power to turn. Both the captain and the first officer told the IIC that the captain was manipulating the controls, not the first officer. During the second interview on November 11, both the captain and first officer indicated that the taxi speed they read from the cockpit ground speed display was 6 or 7 knots. They said that for slippery/icy taxi operations, they are limited to 10 knots or less. The captain wrote in his NTSB Pilot / Operator report that "ground speed was 5-6 knots. I add little power to gain momentum for the turn to N-6. However the a/c slipped to N-2 thru N-4. I tried to stop the a/c by applying brakes to no avail then the a/c continued skidding toward the parked IL-62M on N-2." The Asiana crew said they did not believe there were any preimpact mechanical problems with the airplane. The lead purser on the Boeing 747 stated to the NTSB IIC that when the airplane came to a stop, they did not know why. No one in the cabin felt the impact, no masks fell down, and they did not know there was an accident until the cabin occupants had deplaned. The persons in the cabin thought it was a regular stop, and expected to exit the Boeing by the normal jetway. The purser believed that it took about 20 minutes after they stopped to begin to deplane passengers via a stair truck. The crew of the Ilyushin told the NTSB IIC, through an interpreter provided by Aeroflot, that they were in the main cabin at the time of the collision. They said that immediately after the collision, they turned off all power, and deplaned using air stairs on the right side of the airplane. DAMAGE TO AIRCRAFT The Boeing 747 sustained substantial damage to the left wingtip, and number 1 engine. The number 1 engine and nacelle assembly required removal and replacement. The outboard 10 feet of the left wingtip had to be cut off to separate the airplanes. The Ilyushin was determined by the owner to be beyond economical repair. OTHER DAMAGE Gate N-2 at the international terminal sustained structural damage and was determined to be unusable by the airport authority. The left side of the parked Ilyushin impacted the jetway. The floor structure of the jetway was buckled. A ground handling baggage cart which was positioned near the nose of the Ilyushin was blown over. This cart came to rest halfway between the Ilyushin and the terminal building, in a line directly aft of the exhaust section of the Boeing 747 number one engine. The baggage cart struck an unoccupied van. Two lavatory servicing trucks parked between jetways N-2 and N-4 were blown into each other and sustained minor damage. PERSONNEL INFORMATION Boeing 747-400 The Boeing 747-400 had two flight crews assigned for the flight from New York to Anchorage. The accident crew assumed flight crew positions for the last 3.5 hours of the flight. Both accident crewmen indicated they fly into Anchorage two or three times per month. The Asiana captain was an ex-Korean Air Force pilot. At the time of the accident he had accrued 3,278 hours in the Boeing 747-400. He was hired by Asiana on January 1, 1990. The captain completed a Boeing 747-400 transition check on April 17, 1994. The captain told the NTSB IIC during the first interview on November 11, that he had been flying the Boeing 747(series) for seven years to Anchorage. The captain held a Korean airline transport pilot certificate which was issued to him on September 27, 1975. He completed a type rating in the Boeing 747 on May 19, 1987. He added a rating on his pilot certificate for the Boeing 747-400 on June 11, 1994. The final two flights on the captain's 747-400 training records were shown to be conducted with Korean Ministry of Transport pilots. He also had ratings for the Boeing 737-400, and the Boeing 767-300. The captain held a U.S. first class medical certificate issued on September 21, 1998, with the restriction that he "must have available glasses for near vision." He did not hold any U.S. pilot certificates. A review of the captain's check flight / periodic training records revealed that taxi in / taxi out procedures were completed, with no negative comments. The first officer was also an ex-Korean Air Force pilot. At the time of the accident he had accrued 1,744 hours in the Boeing 747-400. The first officer said he had been flying to Anchorage for three years. He was hired by Asiana on February 6, 1995. The first officer completed an initial check in the Boeing 747-400 on January 13, 1996, and a Korean endorsement for the Boeing 747-400 was added to his Korean pilot certificate on March 8, 1996. He flew as a copilot, with a Korean commercial pilot certificate for three years. He received his Korean airline transport pilot certificate on January 13, 1998, 2 1/2 years after receiving his U.S. airline transport pilot certificate. The first officer held a Korean first class medical certificate issued September 28, 1998. No restrictions were noted on his medical certificate. The first officer completed a U.S. private pilot flight examination in a multiengine airplane on April 28, 1995. He also completed a U.S. commercial pilot flight examination on the same day, April 28, 1995. He completed a U.S. airline transport pilot flight examination on May 1, 1995. According to the Designated Examiner's Report, FAA Form 8710-1, the ground and flight portions of these checks took 0.5 and 0.5 hours for the private; 3.0 and 1.4 hours for the commercial; and 2.0 and 2.0 hours for the airline transport pilot checks, respectively. All three tests were performed by Mr. Clifford Hodges, FAA Designated Examiner number WP-15-02. The recommending instructor for these tests was Mr. Kevin Conley, flight instructor certificate number 562834310. A review of the first officer's check flight / periodic training records revealed that taxi in / taxi out procedures were completed, with no negative comments. Ilyushin IL-62M The flight engineer and navigator were in the cockpit at the time of the collision, preparing the airplane for departure. The two captains and the copilot were in the first class area of the cabin, waiting for the systems on the airplane to warm up. None of the crew reported seeing the Boeing 747 prior to the collision. AIRCRAFT INFORMATION Boeing 747-400 The Boeing 747-400 was operated by a two man cockpit crew. The 747-400 has a fuselage length of 231 feet, and a wingspan of 213 feet. The steering systems employed on this airplane consisted of hydraulically driven nose wheel steering, body gear steering, and wheel brakes. The nose wheel steering receives limited authority input from the cockpit rudder pedals, and full authority input from hand-operated tillers located at both the captain's and first officer's positions. This system is always active, whether the airplane is on the ground or airborne. Body gear steering also is available and is always active. This system consists of hydraulically turning the main landing gear trucks in the opposite direction of the tiller to aid the airplane in turning in a smooth arc. The main landing gear brake system may be used for turning. Additionally, the use of differential thrust on the four wing-mounted engines is available to assist the pilot in ground turning performance. Inspection of the tires of the Boeing 747 revealed that 17 of the 18 tires had deep tread grooves visible. The number eight tire, located on the left main body truck, appeared worn with no visible tread. The 16 main tires pressures ranged from 170 psi to 191 psi. The nose tires pressures were 160 psi, and 175 psi. The outside air temperature at the time of measurement was 20 degrees Fahrenheit. The Asiana Airlines B747 Flight Handbook dated August 01, 1995, page 05-04-02, states, in part: "5. Max taxiing speed (recommended) on idle thrust (1) Turning ... 10 kts or below (5 kts if wet or slippery) (2) On ramp ... 10 kts or below..." On page 05-04-03, the Flight Handbook states, in part: "12. During winter time taxiing...(2) If taxiing on slippery taxiways, ... avoid using large amount of tiller to prevent slipping sideways." Ilyushin IL-62M The IL-62M was a four engine, low wing, airplane manufactured by the Ilyushin Group, Moscow, Russia. The cockpit crewmembers of the Ilyushin consisted of two captains, a copilot, an engineer, a radio operator, and a navigator. The airplane measured 174 feet in length, and had a wingspan of 141 feet. Fuel cells were located in both wings, extending to the tips. In addition, a fuel cell was located in the vertical stabilizer. The vertical stabilizer fuel cell was empty at the time of the collision. The auxiliary power unit (APU) gas turbine was located in the fuselage, underneath the vertical stabilizer. The APU was operating, and was turned off by the crew immediately after the collision. METEOROLGICAL INFORMATION Weather Observations The Anchorage International Airport special weather observation taken at 0118 was, in part: winds from 070 at 4 knots; visibility 1 1/2 miles with light snow and fog; broken clouds at 400 feet and 1,100 feet, overcast clouds at 3,300 feet. The special weather observation taken at 0139, immediately after the accident, was, in part: winds from 060 at 3 knots; visibility 2 miles in light snow and fog; broken clouds at 400 feet and 2,500 feet, overcast clouds at 3,300 feet. Pavement Surface Condition sensor records, taken and maintained by the Anchorage International Airport Operations Department, indicate that surface contamination began to occur between 1355 and 1535 on November 10. At 2320, the Anchorage International Airport Operations log recorded a forecast of "no more than 2 inches expected." Notices to Airmen (NOTAMS) Local (L) NOTAM number 98-248, issued by the Anchorage Airport at 1550 on November 10, stated: "all rwys altnly closed snow removal." Local (L) NOTAM number 98-249, issued by the Anchorage Airport at 1745 on November 10, stated: "caution icy conditions all ramps." NOTAM 98-249 was sent electronically to all tenant air carriers at the Anchorage International Airport, the Anchorage Air Traffic Control Tower, and the Kenai Flight Service Station. This was issued one hour four minutes prior to takeoff, but after the flight crew had received their weather in New York. The airplane was not equipped with an in-flight data link system for receiving updated information from the company while in flight. The Asiana company representative in Anchorage told the NTSB IIC that no additional NOTAM information was passed to Flight 221 via company radio once the airplane was within radio communication range of Anchorage. Anchorage tower Automated Transcribed Information System (ATIS) "Tango" did not include any ramp condition information. Local (L) NOTAM number 981111034001 issued at 1840 Alaska standard time on November 10, stated: "TWYS PTCHY LSR SANDED." This was issued after Asiana Flight 221 departed from New York. The Tapley "decel meter" reading, an indicator of friction, taken on the north ramp immediately after the accident was 0.25 (no units). The Ground Vehicle Friction Correlation Chart (appended) equates a "decel meter" reading between 0.17 and 0.36 to an aircraft "Braking Action Level" of "poor." FAA Advisory Circular (AC) 150/5200-30A, Airport Winter Safety and Operations, states, in part: "Snow, ice, and slush on aircraft movement surfaces can degrade the coefficient of friction and reduce aircraft braking and directional control. ... c. Parking Ramp Operations. Snow, ice, and slush accumulations on ramps and parking or holding areas create safety hazards. Three effects of such accumulations are: (1) Slick Surfaces. Equipment and personnel operating on a

Probable Cause and Findings

The excessive taxi speed by the pilot-in-command. A factor associated with the accident was the pilot's inadequate maneuver to avoid the parked airplane.

 

Source: NTSB Aviation Accident Database

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