Aviation Accident Summaries

Aviation Accident Summary NYC01FA062

Jamaica, NY, USA

Aircraft #1

N769NC

McDonnell Douglas DC-9-51

Analysis

During the takeoff roll, the flight crew heard a "bang;" however, the pilot continued the takeoff and began a climb. The flightcrew was unable to pressurize the passenger cabin, and elected to divert the flight to another airport, where the airplane landed uneventfully. Inspection of the airplane revealed a gash about 3 feet long, by 1 foot wide on the underside of the fuselage, aft of the passenger entry door, and damage to the right nose gear tire. Inspection of the runway at the departure airport revealed an in-ground light cover, that weighted about 100 pounds, was separated from its mount, broken in two pieces, and lying on the runway. Black marks, consistent in color and texture to rubber, and resembling a tire tread, were observed on the optical lighting well, and on the underside of the light fixture. The light cover was part of an in-ground, semi-flush mounted approach lighting fixture installed at the approach end of the runway in 1997. The lighting system had not been commissioned as of the date of the accident due to lack of certification from the FAA. Examination of the light fixture revealed that the six bolts, which were utilized to attach the lighting assembly to the in-ground base, were sheared. The fracture surfaces on the bolts were smeared, consistent with low cycle fatigue fractures that occur over a period of time. The bolts were located on the underside of the fixture, and to inspect them, required removal of the fixture cover. Repairs and inspections of runway lighting facilities at the airport were conducted at varied intervals; however, due to the lack of being commissioned, the in-ground, semi-flush mounted approach lighting fixtures installed at the approach end of the runway were only visually inspected. The runway was inspected for debris and general condition on a daily basis, or on a Duty Manager shift change, in accordance with 14 CFR Part 139.

Factual Information

HISTORY OF FLIGHT On December 27, 2000, about 2033 eastern standard time, a McDonnell Douglas DC-9-51, N769NC, operated by Northwest Airlines Inc., as flight 1865, was substantially damaged during the takeoff roll from John F. Kennedy International Airport (JFK), Jamaica, New York. The 2 pilots, 3 flight attendants, and 22 passengers, were not injured. Night visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight destined for Detroit Metropolitan Airport, Detroit, Michigan. The scheduled passenger flight was conducted under 14 CFR Part 121. According to a representative from the operator, the airplane was on takeoff roll from runway 31L, full length, when at approximately 110 knots, the flightcrew heard a "bang." The pilot continued the takeoff and began a climb. Unable to pressurize the passenger cabin, the pilot elected to divert the flight to Newark International Airport, Newark, New Jersey, where the airplane landed uneventfully. According to a Federal Aviation Administration (FAA) inspector, about 5 minutes after the airplane took-off, a second airplane departed from runway 31L. The airplane reported to the air traffic control tower that they observed an object on the runway. The tower controller alerted the Port Authority of New York and New Jersey Operations Group of the object, who then dispatched airport personnel to investigate. When airport personnel arrived at the approach end of runway 31L, they found a cover from an in-ground light lying on the runway, broken in two pieces. FLIGHTCREW INFORMATION Captain The Captain held an airline transport pilot certificate with a rating for airplane multiengine land, and was type rated in the DC-9. His most FAA first class medical certificate was issued on August 17, 2000. First Officer The First Officer held an airline transport pilot certificate with a rating for airplane multiengine land, and was type rated in a Boeing 707, 720, and 737. His most recent FAA first class medical certificate was issued on April 20, 2000. AIRCRAFT INFORMATION A review of the airplane's maintenance records did not reveal any repetitive discrepancies related to the pressurization system. AERODROME INFORMATION Runway 31L, was a 14,572-foot long, 150-foot wide, asphalt and concrete, grooved runway, with a displaced threshold of 3,323 feet. The light cover recovered on the runway was from an inset flashing light fixture, which was part of an in-ground, semi-flush mounted, medium intensity approach lighting system (MALSR), installed at the approach end of runway 31L in 1997. The lighting system included five separate light fixtures, located within the displaced threshold of runway 31L. The in-ground approach light fixtures were installed in the pavement by a contactor, working for the Port Authority of New York and New Jersey, on behalf of the FAA. The light fixtures were not operational at the time of the accident due to lack of FAA commissioning. According to a representative from the Port Authority of New York and New Jersey, the delay in making the lighting system operational also included the FAA's lack of supplying additional approved light fixtures to complete the approach lighting system project on runway 31L. According to the manufacturer of the lighting system, the semi-flush flashing light fixture was a high intensity flashing light, used in paved operational surfaces of a runway, as a guide for incoming pilots. They were weatherproof and designed to withstand rollover loads. The semi-flush flashing light consisted of a top casting and prism assembly, mirror-holding assembly, and a bracket and filter assembly. The top casting was held to a base mount by six, 1-inch, 3/8-16 threaded bolts, and 3/8 lock washers. The cover was estimated to weigh about 100 pounds. The limitations of the fixture were that "proper maintenance procedures must be adhered to -- the base must be kept reasonably free of water, and proper snow removal and runway clearing procedures must be employed." The manufacturer also warned, "snowplows can cause serious damage to the light objects." According to a representative from the JFK Airport Facilities Division, the last snow removal operations were conducted during the last snow season of 1999-2000. Contracted electricians conducted repairs and inspections of runway lighting facilities at varied intervals. The MALSR lighting fixtures installed at the departure end of runway 31L were not a part of a special maintenance program, due to their being non-operational. The contracted electricians would not be specifically sent to the fixtures to lift the cover and inspect the integrity of the securing bolts; however the electricians would visually check the units during the inspections. The runway was also inspected for debris and general condition on a daily basis, or on a Duty Manager shift change, in accordance with 14 CFR Part 139. WRECKAGE DESCRIPTION Examination of the airplane by an FAA inspector after the accident revealed a gash about 3 feet long, by 1-foot wide on the underside of the fuselage, aft of the passenger entry door. Damage was also observed to the right nose gear tire and two navigation antennas. Safety Board personnel examined the runway on December 29, 2000. Airport maintenance personnel had replaced the area where the affected light fixture cover was installed with a new light fixture cover. Examination of the MALSR light fixtures revealed a layer of epoxy glue, poured into an approximate 1-inch wide void area between the fixture and the runway asphalt. Examination of the accident light fixture by Safety Board personnel, revealed that the six bolts utilized to attach the lighting assembly to the in-ground base were all sheared. The fracture surfaces on the bolts were smeared, consistent with low cycle fatigue fractures that occurred over a period of time. A black mark, consistent with a tire tread, was observed in the optical lighting well of the light fixture. An additional mark, also consistent with a tire tread, was observed on the underside of the light fixture. ADDITIONAL INFORMATION On December 29, JFK facility maintenance electricians inspected the remaining in pavement MALSR light fixtures on runway 31L. The electricians observed, "that while the castings were secured to the base cans, there were a number of 'loose' bolts in each of the remaining 4 fixtures." The airplane was repaired and returned to service on December 29.

Probable Cause and Findings

The low cycle fatigue fracturing of the approach lighting cover securing bolts.

 

Source: NTSB Aviation Accident Database

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