National Transportation Safety Board
Aviation Incident Final Report

 

 

Location:

Chicago, IL

Incident Number:

CHI08IA026

Date & Time:

10/09/2007, 2030 CDT

Registration:

N431UA

Aircraft:

Airbus Industrie A320-232

Aircraft Damage:

Minor

Defining Event:

 

Injuries:

2 Minor, 125 None

Flight Conducted Under:

Part 121: Air Carrier - Scheduled

Analysis

The airplane's left main landing gear inboard and outboard anti skid tachometers wiring were reversed during scheduled maintenance at a vendor.  During landing, the inboard left main landing gear's wheels went to a high braking level and the outboard wheel did not apply braking.  The airplane sustained minor damage when it exited the runway and impacted runway lighting.   Post incident examination of the airplane and brake components revealed no further anomalies.  The vendor that performed the scheduled maintenance indicated that their personnel did not understand that the built in test equipment test they performed did not check for cross-wired tachometers.  A different specified test called out in the airplane maintenance manual and in an operator's reference document indicated this specified check would verify a cross-wired condition.  The operator reported that the reference documentation associated with the scheduled maintenance involving both of the left main landing gear's tachometers was unclear and that the procedure for that maintenance was revised.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this incident to be:
The misrouted and reversed antiskid wiring by vendor maintenance personnel leading to the runway excursion.  Contributing to the incident were the runway sign, the vendor's maintenance personnel not understanding the entire maintenance procedures in the dual tachometer replacement, and the operator's maintenance procedures being unclear to the maintenance personnel.

Findings

 

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTION
Phase of Operation: LANDING

Findings
1. (C) LANDING GEAR,ANTI-SKID BRAKE SYSTEM - MISROUTED
2. (C) BRAKES,ANTI-SKID - REVERSED - OTHER MAINTENANCE PERSONNEL
3. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - LOCKED
4. (F) INTERPRETATION OF INSTRUCTIONS - NOT UNDERSTOOD - OTHER MAINTENANCE PERSONNEL
5. TERRAIN CONDITION - RUNWAY
6. (F) INSTRUCTIONS,WRITTEN/VERBAL - INFORMATION INSUFFICIENT - COMPANY/OPERATOR MANAGEMENT
----------

Occurrence #2: ON GROUND/WATER COLLISION WITH OBJECT
Phase of Operation: LANDING

Findings
7. (F) OBJECT - RUNWAY LIGHT

 

Factual Information

HISTORY OF FLIGHT

On October 9, 2007, about 2030 central daylight time an Airbus Industrie A320-232, N431UA, operated by United Airlines (UA) as flight 628, received minor damage when it exited runway 22R (7,500 feet by 150 feet, grooved asphalt) and impacted runway lighting at the O'Hare International Airport (ORD), Chicago, Illinois.  Two pilots, 2 flight attendants, and 121 passengers were uninjured.  One flight attendant and one passenger reported minor injuries.  The 14 CFR Part 121 scheduled domestic passenger flight was being conducted in night visual meteorological conditions.  An instrument flight rules flight plan was filed and activated.  Flight 628 departed the Seattle-Tacoma International Airport, near Seattle, Washington, about 1649, and was destined for ORD.

The captain said that the preflight, taxi, takeoff, and cruise portions of the flight were uneventful.  The autobrakes were set to low prior to the approach.  The captain's incident report, in part, stated:

 Approach was stabilized to touchdown with about one-half dot low

 deviation at about 500 ft, correcting back to glide slope prior to

 touchdown.  Tower reported winds just prior to touchdown as 300/13.

 Touch down was in the landing area, somewhat harder than

 anticipated.  Reverse Thrust was initiated, but there appeared to be

 no autobraking.

 Approximately 1500-1000 feet prior to intersection of taxiway C, I

 checked airspeed, waited a couple counts for the airspeed to drop

 below 100 kts and commenced braking.  The aircraft immediately

 swerved hard right.  I corrected with full left rudder and brake, but

 aircraft continued to the right.  I then used Nose Wheel Steering to

 attempt to straighten the aircraft, but it was ineffective.  At that time

 the aircraft left the right side of the runway, parallel to the runway,

 contacted at least one sign, and then began to track left, back onto

 the paved surface.  Aircraft stopped on runway and taxied clear at

 [taxiway] R.

 Although I knew there was some aircraft damage, there was no

 indication of fire.  Since the aircraft taxied normally, I taxied to gate

 B-10 and parked at the gate.

 At the gate, brake temp indications showed no temp rise on the left

 brakes (indicating about 60 degrees), while the right brakes were in

 the overheat temperature about 375 degrees.  At that point

 maintenance arrived and said there was damage to the engine nacelles

 and the left inboard tire was blown.

The first officer's incident report, in part, stated:

 Captains leg on landing 22R wind 300/17G23 on the ATIS.  Briefed

 a flaps 3 landing for the crosswind.  Firm touchdown in the landing

 zone.  Spoilers deployed and reverse activated.  We were coming up

 to C still above 80 knots.  Applied brakes firmly and plane swerved

 to the right.  Checked to make sure captain had full left rudder and

 full left brake.  He did.  As we departed the right side of the runway

 saw the Captain was using steering to get us back on.  He did.  The

 right Main and nose wheel exited the runway.  Once stopped back

 on the runway we informed tower of our excursion from the runway. 

 They told the plane behind us to go around.  We determined that we

 could taxi ok and decided we could clear the runway.  Once clear it

 felt like it was taxiing ok so we continued to the gate.  We left the

 flaps and spoilers in position in case of damage.  The left brake

 temps were around 60 degrees like they never came on and the

 right were 390.  I forgot to add that we had the auto brakes set to

 LO.  Neither of us felt them engage on the rollout.

 

INJURIES TO PERSONS

According to the operator, one flight attendant and one passenger went to a hospital for examination.  The attendant and passenger subsequently released themselves from the hospital.

 

PERSONNEL INFORMATION

The captain held an airline transport pilot certificate with an airplane multiengine land rating and held airplane single engine land commercial privileges.  He held a flight engineer certificate.  The captain held type ratings in Airbus A-320, Boeing 757, 767, 777, and Gulfstream Aerospace Corporation-1159 airplanes.  The operator reported that the captain had accumulated about 14,250 hours of total flight experience, which included 2,450 hours in the Airbus A-320.  The operator reported that the captain's most recent Federal Aviation Administration (FAA) first class medical certificate was issued on April 27, 2007.  His last check ride was completed in June 2007.

The first officer held an airline transport pilot certificate with an airplane multiengine land rating and held airplane single engine land commercial privileges.  He held a flight engineer certificate.  The first officer held type ratings in Airbus A-320, Learjet, and Learjet-45 airplanes.  He had held a certified flight instructors certificate with single engine, multiengine, and instrument airplane ratings.  The operator reported that the first officer had accumulated about 10,206 hours of total flight experience, which included 268 hours in the Airbus A-320.  The operator reported that the first officer's most recent FAA first class medical certificate was issued on March 15, 2007.  His last check ride was completed in July 2007.

 

AIRCRAFT INFORMATION

N431UA, an Airbus Industrie A320-232, serial number 571, was a pressurized, low-wing, transport category airplane.  The airplane had a full-cantilevered wing and tail surfaces, a semi-monocoque fuselage, and a fully retractable tricycle landing gear.  The two wing-mounted IAE 2527 turbofan engines each produced 26,500 lbs of thrust.  The airplane was configured to accommodate 138 passengers and 8 crewmembers.  The airplane had a reported maximum gross takeoff weight of 169,750 lbs.

The airplane was being maintained by compliance with a FAA approved continuous airworthiness program.  The airplane's last inspection was completed on 10/8/07.  According to the operator, the airplane had accumulated 41,163 hours total time in service at that inspection.

The airplane was equipped with brakes and anti-skid system.  The section on that system in the airplane's flight crew operating manual supplied by UA, in part, stated:

 The main wheels have multidisc brakes that can be actuated by either

 of two independent brake systems.  The normal system uses green

 hydraulic pressure: the alternate system uses the yellow hydraulic

 system backed up by a hydraulic accumulator.  An anti-skid system

 and autobraking work through the brake system.  Braking commands

 come from either the brake pedals (pilot action) or the autobrake

 system (deceleration rate selected by the crew).  ... All braking

 functions (normal and alternate braking control, anti-skid, autobraking,

 brake temperature indication) are controlled by a two-channel Brake

 and Steering Control Unit (BSCU).  ...

 ANTI-SKID SYSTEM

 The anti-skid system produces maximum braking efficiency by

 maintaining the wheels just short of an impending skid.  When a

 wheel is on the verge of locking, the system sends brake release

 orders to the normal and alternate servovalves - and to the ECAM

 [electronic centralized aircraft monitoring], which displays the

 released brakes.  ...

 The system compares the speed of each main gear wheel (given by

 a tachometer) with the speed of the aircraft (reference speed).  When

 the speed of a wheel drops below 0.87 times the reference speed, the

 system orders brake releasing in order to maintain the brake slip at

 that value (best braking efficiency).

 AUTO BRAKE

 The purposes of this system are:

 - to reduce the braking distance in case of an aborted takeoff.

 - to establish and maintain a selected deceleration rate during

 landing, thereby improving passenger comfort and reducing crew

 workload.

 ARMING

 The system arms when the crew presses the LO, MED, or MAX

 pushbutton switch if:

 - Green pressure is available.

 - The anti-skid system has electric power.

 - There is no failure in the braking system.

 - At least one ADIRS [air data/inertial reference system] is functioning.

 ACTIVATION

 Automatic braking commences when the ground spoilers extend ... . 

 For autobrakes to activate, at least two SEC's [spoiler elevator

 computer] must be operative.

 DISARMING

 The system disarms when:

 - Flight crew presses the pushbutton switch or,

 - One or more arming conditions is lost or,

 - Flight crew applies enough deflection to one brake pedal when

 autobrake is operating in MAX, MED, or LO mode.

 - The ground spoilers retract ... .

 - The aircraft has been in flight for 10 seconds.

The airplane maintenance manual stated that "four identical tachometers are installed in the main gear wheel axles (one for each wheel)."

The operator, in part, reported:

 From September 18, 2007 through September 23, 2007, N431UA

 had a Scheduled Special Route (SSR) maintenance visit accomplished

 by UA maintenance contractor Triad International Maintenance

 Corporation (TIMCO).  The SSR maintenance visit included

 accomplishment of UA Change Order Authorization (COA) #405779

 "Left Hand Main Landing Gear Sliding Tube Replacement." 

 The aircraft was released from TIMCO on September 23 and

 subsequently flew 68 cycles.  ...  A review of maintenance history

 found that the last time the #1 and #2 anti skid connectors were

 disturbed was during the SSR visit.

The airplane maintenance manual had a job task that lists procedures for a functional test of the tachometers.  That task can show if the identical tachometers have been wired incorrectly.  That task is not mandatory if only one of the two tachometers on a main landing gear axle has been replaced or disconnected.  The airplane maintenance manual called out that task as soon as more than one of the tachometers had been replaced or disconnected.  The COA contained callouts EG7629, EG7630, EG7625, and EG7627, which used the procedures to test for incorrect wiring of the tachometers.

 

METEOROLOGICAL INFORMATION

At 1551, the ORD weather was: Wind 280 degrees at 14 knots gusting to 19 knots; visibility 10 statute miles; sky condition scattered 25,000; temperature 23 degrees C; dew point 4 degrees C; altimeter 30.06 inches of mercury.

 

AIRPORT INFORMATION

ORD was located approximately 14 miles northwest of Chicago, Illinois, and was owned and operated by the city of Chicago, Illinois.  ORD was a certificated airport under 14 CFR Part 139.  ORD 's field elevation was 668 feet above mean sea level.  ORD had 6 runways: Runway 14R/32L - 13,000 feet by 200 feet, asphalt/concrete/grooved; runway 10/28 - 10,144 feet by 150 feet, asphalt/concrete/grooved; runway 14L/32R - 10,005 feet by 150 feet, asphalt/concrete/grooved; runway 4R/22L - 8,075 feet by 150 feet, asphalt/grooved; runway 9R/27L - 7,967 feet by 150 feet, asphalt/concrete/grooved; and runway 4L/22R - 7,500 feet by 150 feet, asphalt/grooved.

Runway 22R was marked as a precision approach runway and had high intensity runway edge lights.  A four-light, three-degree, precision approach path indicator serviced runway 22R.  Runway 22R had MALSR (medium intensity approach lighting system with runway alignment indicator lights) approach lighting.  The runway had centerline and touchdown zone lighting. 

 

FLIGHT RECORDERS

Cockpit Voice Recorder

The airplane was equipped cockpit voice recorder (CVR).  The CVR was not read out.

Flight Data Recorder

The airplane was equipped with a digital flight data recorder (DFDR).  The operator provided a readout of the DFDR data for the landing.

Review of the DFDR data showed that the autobrake system was armed in the low mode on approach.  The autobrake system was disarmed when toe pressure was placed on the brake pedals.  The recorded aircraft heading showed a drift to the right.  The left main landing gear inboard brake went to a high-recorded pressure.  The left main landing gear outboard brake pressure went to a low recorded pressure.  The data showed the left rudder pedal was depressed and the left brake pedal angle increased.  The recorded aircraft heading showed a continued drift to the right.  The tiller angle data showed the tiller was turned to the left.

 

WRECKAGE AND IMPACT INFORMATION

FAA inspectors and representatives of the operator examined the airplane after the incident.  The examination found the number one and number two brake anti skid tachometer electrical connectors were reversed.

 

MEDICAL AND PATHOLOGICAL INFORMATION

FAA required post incident toxicological tests were performed on the flight crew.  Both flight crewmembers submitted specimens for drug screening following the incident.  The tests were all negative.

 

TESTS AND RESEARCH

Braking components were sent to their manufacturer for examination and testing.

The examination of the tachometers, part number C20105000, revealed that the number one tachometer, serial number 7318, and the number two tachometer, serial number 7315, exhibited no anomalies that would have precluded operation of the tachometers.

The examination of the servovalves, part number C20374000-2, revealed that the number one servovalve, serial number 50542, and the number two servovalve, serial number 2405, exhibited no anomalies that would have precluded operation of the servovalves.

The examination of the BSCU, part number C202163382-D32, serial number 997, revealed that the unit exhibited no anomalies that would have precluded operation of the BSCU.

The left and right main landing gear (MLG) tires were sent to their manufacturer for examination.  The report from the examination showed that the left MLG inboard tire had a large skid-through type abrasion.  The tire had a rupture that extended down both sidewalls into the bead areas.  The skid abrasion centered around the opposite serial number side shoulder rib area.  The left MLG outboard tire had lateral abrasion on the opposite serial number side shoulder tread rib.  The center tread rib had lateral abrasion and rib edge chunking.  Most of the tread had lateral scuffmarks.  The center tread rib had a cut that was approximately an inch in diameter and extended into the protector ply.

The overhaul facility interviewed their maintenance personnel.  The interviews revealed that the 1M and 2M wiring harnesses for the number one and number two tachometers were mislabeled when they were removed for the SSR maintenance.  The overhaul facility, in part, reported:

 The Change Order Authorization Job Instruction Card (COAJIC)

 contained step 26 which directly required the maintenance personnel

 to perform a build in test equipment (BITE) test of the landing gear

 in accordance with aircraft maintenance manual (AMM) 32-69-00-740-001. 

 The COJIC contained step 17 which stated, "PREPARE FOR

 REPLACEMENT OF SLIDING TUBE AS FOLLOWS: ... C.)

 INSTALL THE TACHOMETERS PER AMM 32-42-57-400-001." 

 The procedure in AMM 32-42-57-400-001 listed step E that stated,

 "Test (1) Do the functional test of the tachometer (Ref. AMM TASK

 32-42-00-720-002)."  TASK 32-42-00-720-002 listed the steps

 necessary to accomplish the functional test of the tachometers.  The

 personnel completing the maintenance thought that the BITE test

 would confirm proper harness connections.  The BITE test did not

 verify each tachometer's connected position.  The BITE test only

 indicated that a tachometer is connected to the wiring harness and

 is operational.

 

ADDITIONAL DATA/INFORMATION

FAA Airworthiness Directive (AD) 2007-11-11, in part, stated:

 This AD results from a determination that additional inspections and

 mandatory replacement of the main landing gear (MLG) shock

 absorbers are necessary.  We are issuing this AD to detect and

 correct cracking in an MLG sliding tube, which could result in

 failure of the sliding tube, loss of one axle, and consequent

 reduced controllability of the airplane.

Subsequent to Voluntary Disclosure Reporting Program report, UA sent a letter, dated December 10, 2007, to a FAA Certificate Management Office that, in part, reported:

 Documentation associated with COA 405779, which accomplished

 AD2007-11-11 on the LH MLG, and COA 40577A which

 accomplished AD2007-11-11 on the RH MLG, was found to be

 unclear regarding the requirement to perform a functional test of the

 tachometers following their installation.  ...

 Based on interviews with both Timco ... and United ... maintenance

 personnel involved with similar activities, it was also determined

 that the potential for this to occur during the replacement of either

 MLG also existed.  United Work Documents reviewed the LH and

 RH MLG replacement JIC packages for the Airbus fleet and found

 the instructions provided to install and functional check the

 tachometers to be the same as in the COAJICs that accomplished

 AD2007-11-11.  This was inconsistent with the Work Documents

 Operating Procedures (WDOP) manual and the JIC package was

 immediately revised to provide proper instructions and ensure that

 a functional check of each tachometer is performed.  To further

 terminate the conduct that resulted in this apparent violation, and

 ensure that any aircraft that had maintenance performed on it using

 either of the COAJICs or the MLG JIC package, we performed

 functional checks on the tachometers of a total 45 Airbus aircraft

 per Airbus AMM subtask 32-42-00-720-002 (this included 18 aircraft

 per EG7662 that have received MLG changes using the JIC package). 

 Of the 45 aircraft checked, only [the incident airplane and another

 airplane] were found to have been assembled improperly.

According to preliminary information supplied to the NTSB, on February 25, 2008, at 9:16 p.m. MST, United Airlines flight 267, an Airbus A-320, registration N442UA, departed the right side of runway 19 during landing at Jackson Hole Airport, Jackson, Wyoming.  Examination of that airplane's left main landing gear brake system revealed that the inboard and outboard wheel speed tachometer wires were cross-connected.  The NTSB report number for that incident is DCA08IA044.

The parties to the investigation were the FAA, Triad International Maintenance Corporation, and United Airlines.  The French Bureau d' Enquetes et d'Analyses (BEA) provided an accredited representative to the investigation.  Airbus Industrie provided a technical representative to the investigation.

 

 

 

Pilot Information

Certificate:

Airline Transport; Commercial; Flight Engineer

Age:

57, Male

Airplane Rating(s):

Multi-engine Land; Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

Seatbelt, Shoulder harness

Instrument Rating(s):

Airplane

Second Pilot Present:

Yes

Instructor Rating(s):

None

Toxicology Performed:

No

Medical Certification:

Class 1 Without Waivers/Limitations

Last FAA Medical Exam:

04/01/2007

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

06/01/2007

Flight Time:

14250 hours (Total, all aircraft), 2450 hours (Total, this make and model), 6450 hours (Pilot In Command, all aircraft), 196 hours (Last 90 days, all aircraft), 75 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)

 

 

Co-Pilot Information

Certificate:

Airline Transport; Flight Instructor; Commercial; Flight Engineer

Age:

45, Male

Airplane Rating(s):

Multi-engine Land; Single-engine Land

Seat Occupied:

Right

Other Aircraft Rating(s):

None

Restraint Used:

Seatbelt, Shoulder harness

Instrument Rating(s):

Airplane

Second Pilot Present:

Yes

Instructor Rating(s):

Airplane Multi-engine; Airplane Single-engine; Instrument Airplane

Toxicology Performed:

No

Medical Certification:

Class 1 Without Waivers/Limitations

Last FAA Medical Exam:

03/01/2007

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

07/01/2007

Flight Time:

10206 hours (Total, all aircraft), 268 hours (Total, this make and model), 6351 hours (Pilot In Command, all aircraft), 141 hours (Last 90 days, all aircraft), 50 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

Airbus Industrie

Registration:

N431UA

Model/Series:

A320-232

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Transport

Serial Number:

571

Landing Gear Type:

Retractable - Tricycle

Seats:

146

Date/Type of Last Inspection:

10/01/2007, Continuous Airworthiness

Certified Max Gross Wt.:

169750 lbs

Time Since Last Inspection:

 

Engines:

2 Turbo Fan

Airframe Total Time:

41163 Hours as of last inspection

Engine Manufacturer:

IAE

ELT:

Installed

Engine Model/Series:

2527

Registered Owner:

U S BANK NA TRUSTEE

Rated Power:

26500 lbs

Operator:

UNITED AIR LINES INC

Operating Certificate(s) Held:

Flag carrier (121)

Operator Does Business As:

 

Operator Designator Code:

UALA

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Night

Observation Facility, Elevation:

ORD, 668 ft msl

Distance from Accident Site:

 

Observation Time:

1951 CDT

Direction from Accident Site:

 

Lowest Cloud Condition:

Clear

Visibility

10 Miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

17 knots / 23 knots

Turbulence Type Forecast/Actual:

/

Wind Direction:

300°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

29.91 inches Hg

Temperature/Dew Point:

16°C / 4°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

SEATTLE, WA (SEA)

Type of Flight Plan Filed:

IFR

Destination:

Chicago, IL

Type of Clearance:

IFR

Departure Time:

1649 CDT

Type of Airspace:

 

 

Airport Information

Airport:

CHICAGO O'HARE INTL (ORD)

Runway Surface Type:

Asphalt

Airport Elevation:

668 ft

Runway Surface Condition:

Dry

Runway Used:

22R

IFR Approach:

Visual

Runway Length/Width:

7500 ft / 150 ft

VFR Approach/Landing:

Full Stop

 

Wreckage and Impact Information

Crew Injuries:

1 Minor, 4 None

Aircraft Damage:

Minor

Passenger Injuries:

1 Minor, 121 None

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

2 Minor, 125 None

Latitude, Longitude:

41.968611, -87.907778 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Edward F Malinowski

Report Date:

12/24/2008

Additional Participating Persons:

William W Carmichael; Federal Aviation Administration; Des Plaines, IL

Jeff Plantz; United Airlines; Chicago, IL

Dave Lattimer; TIMCO Aviation Services, Inc.; Greensboro, NC

Philippe Mauviot; French Bureau d' Enquetes et d'Analyses (BEA); Paris, France,  

Marc Baillion; Airbus Industrie; Blagnac Cedex France,

Publish Date:

12/24/2008

Investigation Docket:

NTSB accident and incident dockets serve as permanent archival information for the NTSB’s investigations. Dockets released prior to June 1, 2009 are publicly available from the NTSB’s Record Management Division at pubinq@ntsb.gov, or at 800-877-6799. Dockets released after this date are available at http://dms.ntsb.gov/pubdms/.