American Airlines Flight 587. Airbus Industrie A300-605R, N14053. Belle Harbor, New York. November 12, 2001. Aircraft Accident Report. NTSB/AAR-04/04.
212 pages
107 KB – 212 Pages
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National Transportation Safety BoardWashington, D.C. 20594 OFFICIAL BUSINESSPenalty for Private Use, $300PRSRT STDPostage & Fees Paid NTSBPermit No. G-200 In-Flight Separation of Vertical Stabilizer American Airlines Flight 587 Airbus Industrie A300-605R, N14053 Belle Harbor, New York November 12, 2001Aircraft Accident ReportNTSB/AAR-04/04PB2004-910404Notation 7439BNational Transportation Safety BoardWashington, D.C.National Transportation Safety BoardWashington, D.C.
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Aircraft Accident Report In-Flight Separation of Vertical Stabilizer American Airlines Flight 587 Airbus Industrie A300-605R, N14053Belle Harbor, New York November 12, 2001NTSB/AAR-04/04 PB2004-910404National Transp ortation Safety BoardNotation 7439B490 L™Enfant Plaza, S.W. Adopted October 26, 2004Washington, D.C. 20594 E PLURIBUS UNUM NATIONAL TRASPORTATION BOARDSAFETYN
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National Transportation Safety Board. 2004. In-Flight Separation of Vertical Stabilizer, American Airlines Flight 587, Airbus Industrie A300-605R, N14053, Belle Harbor, New York, November 12, 2001. Aircraft Accident Report NTSB/AAR-04/04. Washington, DC. Abstract: This report explains the accident involving American Airlines flight 587, an Airbus Industrie A300-605R, N14053, which cr ashed into a residential area of Belle Harbor, New York, following the in-flight separation of the ai rplane™s vertical stabilizer and rudder. The safety issues discussed in this report focus on characteristics of the A300- 600 rudder control system design, A300-600 rudder pedal inputs at high airspeeds, aircraft-pilot coupling, flight operations at or below an airplane™s design mane uvering speed, and upset recovery training programs. Safety recommendations concerni ng these issues are addressed to the Federal Aviation Administration and the Direction Général de l™Aviation Civile. The National Transportation Safety Board is an independent Federal agency dedicated to promoting av iation, railroad, highway, m arine, pipeline, and hazardous ma terials safety. Established in 1967, the agency is mandated by Congress through the Independent Safet y BoardAct of 1974 to investigate transportation ac cidents, determine the probable causes of the accidents, issue safety recommendatio ns, studytransportation safety issues, and evaluate the safety effectiveness of government agen cies involved in transportation. The Safe ty Board makes public its acti ons and decisions through ac cident reports, safety st udies, special investigation reports, safety recommen dations, and statistical reviews. Recent publications are available in thei r entirety on the Web at
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iiiAircraft Accident Report ContentsFigures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v iiAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi 1.Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.3Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.4Other Damage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5.1The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5.1.1Pilot Interviews Regarding the Captain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.5.2The First Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 11.5.2.1Pilot Interviews Regarding the First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.6Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 41.6.1Vertical Stabilizer and Rudder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.6.2Rudder Control System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.6.2.1Public Hearing Testimony on the A300-600 Rudder Control System . . . . . . . . 23 1.6.2.2Airbus Changes to the A300-600 Rudder Control System Design . . . . . . . . . . . 24 1.6.2.3A300-600 Rudder Control System Design Compared With Other Airplanes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.6.3Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291.6.4Airplane Certification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.6.4.1Loads Certification for the Vertical Stabilizer . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.6.4.1.1Federal Aviation Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.6.4.1.2Public Hearing Testimony on Section 25.351. . . . . . . . . . . . . . . . . . . . . . . . 33 1.6.4.1.3Complementary Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.6.4.2Design Loads for the Vertical Stabilizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.6.4.3Vertical Stabilizer Certification Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.6.4.3.1Validity of the Full-Scale Vertical Stabilizer Certification Test. . . . . . . . . . 39 1.6.4.3.2Validity of the Attachme nt Fitting Certification Tests . . . . . . . . . . . . . . . . . 40 1.6.4.4Yaw Axis Certification Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 1.6.4.5Design Maneuvering Speed Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1.6.5Maintenance Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.7Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 1.8Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461.9Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461.10Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 1.10.1Air Traffic Control Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 1.11Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 1.11.1Cockpit Voice Recorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 1.11.2Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
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ivAircraft Accident Report 1.12Wreckage and Impact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 1.12.1General Wreckage Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 1.12.2Vertical Stabilizer and Rudder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 1.12.3 Rudder Control System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 1.12.4Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521.13Medical and Pathological Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 1.14Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 1.15Survival Aspects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 1.16Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 1.16.1Video Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531.16.2Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 1.16.2.1Wake Vortex Investig ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 1.16.2.2Flight 587 Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 1.16.2.3Loads on the Vertical Stabilize r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 1.16.3Examinations of the Flight 587 Vertical Stabilizer and Rudder . . . . . . . . . . . . . . . 61 1.16.3.1Nondestructive Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 1.16.3.2Materials Testing and Microstructural Examin ation. . . . . . . . . . . . . . . . . . . . . . 63 1.16.3.3 Fractographic Examinatio n of the Main Attachment Lugs . . . . . . . . . . . . . . . . 64 1.16.4Structural Analyses and Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 1.16.4.1Finite Element Analysis and Progressive Fa ilure Analysis. . . . . . . . . . . . . . . . . 66 1.16.4.2Postaccident Lug Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 1.16.4.3Summary of Structural Analys es and Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 1.16.5Systems Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 11.16.5.1Rudder Servo Controls and Li nkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 1.16.5.2Artificial Feel and Trim Unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 1.16.5.3Rudder Control System Ground Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 1.16.5.4Yaw Autopilot and Yaw Damper Actuators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 1.16.5.5Flight Control Linkages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 1.16.6Human Performance Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 1.16.6.1Vertical Motion Simulator Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 1.16.6.2Control Force and Control Surface Disp lacement Ground Tests . . . . . . . . . . . . 74 1.16.7Temperature Tab Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 1.16.8Cockpit Voice Recorder Sound Spectrum Study. . . . . . . . . . . . . . . . . . . . . . . . . . . 76 1.16.9Speech Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771.17Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 1.17.1Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 1.17.1.1Selected Event Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 1.17.1.2Advanced Aircraft Maneuvering Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 1.17.1.2.1 Development of the Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 1.17.1.2.2Ground School Training In formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 1.17.1.2.3Simulator Training Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 1.17.1.2.4Training Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 1.17.1.2.5Comments on the Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 1.17.1.2.6Training Simulator Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 1.17.1.2.7Comparison of Rudder Pedal Responses in the A300-600 Airplane and the American Air lines A310/300 Training Simulator . . . . . . . . . . . . . . 91 1.17.1.3Postaccident A300 Pilot Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 1.17.2Flight and Operations Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 1.17.2.1Use of Rudder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 1.17.2.1.1Manufacturer™s Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Contents
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viAircraft Accident Report 2.3.2.2.1Ground School Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 2.3.2.2.2Simulator Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 2.3.2.3Lack of Pilot Training on Restricted A300-600 Rudder Pedal Travel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 2.3.3Characteristics of the A300-600 Rudder Control System Design . . . . . . . . . . . . . 144 2.4Analysis of the Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.4.1Initial Rudder Pedal Input . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.4.1.1 First Officer™s Reactions to Wake Turbul ence Encounters . . . . . . . . . . . . . . . 147 2.4.1.2Training Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 2.4.1.3A300-600 Rudder Control System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 2.4.2Subsequent Rudder Pedal Inputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 2.4.2.1Role of Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 2.4.2.2Airplane Response to Initi al Input as Triggering Event for an Adverse Aircraft-Pilot Coupling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 2.4.2.3Characteristics of the A300-600 Rudder Control System Design That May Be Conducive to Sustained Alternating Inputs . . . . . . . . . . . . . . . . . . . . . . 151 2.4.3Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 22.5Prevention of High Loads Resulting From Pilot Rudder Pedal Inputs. . . . . . . . . . . . . 153 2.5.1Rudder Pedal Inputs at High Airspeeds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 2.5.2Alternating Full Control Inputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 2.5.3Pilot Guidance on Design Maneuvering Speed . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 2.6Upset Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 3.Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 3.1Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 3.2Probable Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1604.Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 4.1New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 4.2Previously Issued Recommendations Resulting From This Accident Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 4.3Previously Issued Recommendation s Classified in This Report . . . . . . . . . . . . . . . . . 164 5.Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 A: Investigation and Public Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 C: Differences Between American Airlines Flights 903 and 587. . . . . . . . . . . . . . . . . . 197 Contents
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viiAircraftAccidentReport Figures1. Control Wheel and Rudder Pedal Movements Duri ng the Second Wake Encounter. . . . . . . 6 2. American Airlines Flight 587 and Japan Air Lines F light 47 Flightpaths. . . . . . . . . . . . . . . 7 3. Flight 587™s Flightpath and Key Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4. Vertical Stabilizer-to-Aft Fuselage Attachment Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 5. Main Attachment Lug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176. Rudder Control System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197. Rudder Travel Limiter System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 8. A300-600 and A300B2/B4 Rudder Pedal Sensitivities. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 9. Shear, Bending, and Torsion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 710. Net Torsion Versus Net Bending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 11. Vertical Stabilizer After Recovery From Jamaica Bay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 12. Right Rear Main Attachment Fitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 13. Bending Moment About the Root Chord in the Ver tical Stabilizer Axis System. . . . . . . . . 58 14. Bending Moment Load Range at the Time of Ver tical Stabilizer Separation . . . . . . . . . . . 60 15. Estimated Aerodynamic Loads in Relation to the Torsion Versus Bending Correlated Shear Force Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 16. Comparison of Lug Forces at the Ti me of Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 17. Load on the Flight 587 Right Rear Main Attachment Lug and a Depiction of the Cleavage-Tension Failure Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 18. Rudder Pedal Motion With Normal and Hi gh Pilot Pedal Force in the A300-600 Airplane and the American Airlines A310/300 Traini ng Simulator. . . . . . . . . . . . . . . . . . . 91
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viiiAircraftAccidentReport AbbreviationsAAMPadvanced aircraft maneuvering programACadvisory circularADairworthiness directive AFMairplane flight manualAFSauto flight systemaglabove ground levelAOAangle of attackAPCaircraft-pilot couplingAPMaircrew program managerAPUauxiliary power unitASOSautomated surface observing system ASR-9airport surveillance radar-9 ASRSaviation safety reporting systemATC air traffic control ATCT air traffic control tower ATIS automatic terminal information service ATP airline transport pilotCCelsius CCcomplementary conditionsCFDcomputational fluid dynamicsCFITcontrolled flight into terrainCFRCode of Federal RegulationsCFRPcarbon fiber reinforced plasticscgcenter of gravityCMOcertificate management office CTcomputed tomography
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AbbreviationsixAircraftAccidentReport CVRcockpit voice recorderDGACDirection Général de l™Aviation Civile EICASengine instrument crew alert systemFAA Federal Aviation Administration FARs Federal Aviation Regulations FBIFederal Bureau of InvestigationFCOMflight crew operating manualFDAUflight data acquisition unitFDRflight data recorderFEAfinite element analysis GFRP glass fiber reinforced plasticHBAT handbook bulletin for air transportationHgmercuryHzHertzJFKJohn F. Kennedy International Airport KCAS knots calibrated airspeedkNkiloNewtonMACmean aerodynamic chordMETAR meteorological aerodrome reportMIA Miami International AirportMPDmaintenance planning documentMRBmaintenance review boardmslmean sea levelNNewtonNASA National Aeronautics and Space Administration nmnautical mileNmNewton times meter(s)NPRMnotice of proposed rulemakingNRCNational Research Council
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