空难调查报告阿拉斯加航空261班机

1、NTSB/AAR-02/01PB2002-910402Aircraft Accident ReportLoss of Control and Impact with Pacific Ocean Alaska Airlines Flight 261 McDonnell Douglas MD-83, N963ASAbout 2.7North ofAnacapa Island, California January 31, 2000NationalTransportation Safety BoardWashington, D.C.ROAircraft Accident ReportLoss of

2、Control and Impact with Pacific Ocean Alaska Airlines Flight 261McDonnell Douglas MD-83, N963ASAbout 2.7North ofAnacapa Island, California January 31, 2000NTSB/AAR-02/01 PB2002-910402Notation 7263EAdopted December 30, 2002National Transportation Safety Board490 L?Enfant Plaza, S.W. Washington, D.C.

3、20594RONational Transportation Safety Board. 2003. Loss of Control and Impact with Pacific Ocean, AlaskaAirlines Flight 261, McDonnell Douglas MD-83, N963AS, About 2.7North of Anacapa Island,California, January 31, 2000. Aircraft Accident ReporSB/AAR-02/01. Washington, DC.Abstract: This report expla

4、ins the accident involving Alaska Airlines flight 261, a McDonnell DouglasMD-83, which crashed into the Pacific Ocean about 2.7north of Anacapa Island, California.Safety issues discussed in this report include lubrication and inspection of the jackscrewassembly, extension of lubrication and end play

5、 check intervals, jackscrew assembly overhaul procedures, the design and certification of the MD-80 horizontal stabilizer trim control system, Alaska Airlines? maintenance program, and Federal Aviation Administration (FAA) oversight of Alaska Airlines. Safety recommendations a dressed to the FAA.The

6、 National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transpo

7、rtation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public it ions and decisions through accident reports,

8、safety studies, special investigation reports, safety recommendations, and statistical reviews.Recent publications are available in their entirety on the Web at <>. Other information about available publications also may be obtained from the Web site or by contacting:National Transportation Sa

9、fety Board Public Inquiries Section, RE-51490 L?Enfant Plaza, S.W.Washington, D.C. 20594(800) 877-6799 or (202) 314-6551Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report numbe

10、r PB2002-910402 from:National Technical Information Service 5285 Port Royal RoadSpringfield, Virginia 22161(800) 553-6847 or (703) 605-6000The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident

11、or accident in a civil action for damages resulting from a matter mentioned in the report.iiiAircraft Accident ReportContentsAbbreviationsixExecutive Summaryxii1. Factual Information11.11.21.31.41.5History of Flight1Injuries tos10Damage to Airplane10Other Damage10nel Information101.5.11.5.2The Capta

12、in10The First Officer111.6Airplane Information111.6.11.6.1.11.6.1.21.6.1.31.6.2MD-80 Longitudinal Trim Control System Information13Primary Trim Control System18Alternate Trim Control System18Autopilot Pitch Control19Design and Certification of MD-80 Series Airplanes191.6.2.1General191.6.2.2Longitudi

13、nal Trim Control System Certification191.6.3Maintenance Information241.6.3.1Alaska Airlines? MD-80 Maintenance Program241.6.3.1.11.6.3.1.21.6.3.1.3Maintenance Program Development Guidance24Alaska Airlines? Continuous Airworthiness Maintenance Program26Alaska Airlines? Reliability Analysis Program261

14、.6.3.2Jackscrew Assembly Lubrication Procedures291.6.3.2.1Jackscrew Assembly Lubrication Intervals311.6.3.2.1.11.6.3.2.1.2Manufacturer-Recommended Lubrication Intervals31Alaska Airlines? Lubrication Intervals321.6.3.2.21.6.3.2.3Chronology of Grease Type Changes34July 19, 2002, Alaska Airlines Mainte

15、nance Information Letter361.6.3.3Procedures for Monitoring Act ThWear371.6.3.3.11.6.3.3.2Defining and Calculating Wear Rate37Development of End Play Check Procedures381.6.3.3.2.1Alaska Airlines? End Play Check Procedure431.6.3.3.3Horizontal Stabilizer Restraining Fixture441.6.3.3.3.11.6.3.3.3.2Gener

16、al44Alaska Airlines-Manufactured Restraining Fixtures441.6.3.3.4End Play Check Intervals471.6.3.3.4.1Manufacturer-Recommended End Play Check Intervals47Alaska Airlines? End Play Check Intervals471.6.3.3.4.21.6.3.4Accident Airplane?s Maintenance Information491.6.3.4.1Accident Airplane?s Last C Check

17、Requiring an End Play Check50ContentsivAircraft Accident Report1.6.3.4.2Maintenancenel Statements Regarding the AccidentAirplane?s Last End Play Check531.71.81.9Meteorological Information54Aids to Navigation54Communications541.10 Airport Information551.11 Flight Recorders551.11.1 Cockpit Voice Recor

18、der551.11.1.1 CVR Sound Spectrum Study551.11.2 Flight Data Recorder561.12 Wreckage and Impact Information571.12.1 General571.12.2 Horizontal Stabilizer Jackscrew Assembly Components581.131.141.151.16Medical and Pathological Information62Fire62Survival Aspects62Tests and Research631.16.1 Airplane Per

19、formance631.16.1.1 Airplane Performance Simulation Studies661.16.2 Metallurgical Examinations671.16.2.11.16.2.21.16.2.31.16.2.41.16.2.51.16.2.6Horizontal Stabilizer Forward Spar67Acme Screw68Acme Screw Torque Tube70Lower Mechanical Stop and Corresponding Spline Area on the Acme Screw71Ac Act72t ThRe

20、mnant Examination761.16.3Shear Load Capability of the Act Ths771.16.41.16.51.16.6Studies of ThStress and Deformation77Torque Tube Testing79Additional Safety Board Jackscrew Assembly Examinations801.16.6.11.16.6.21.16.6.3February 2000 Post-AD 2000-03-51 Jackscrew Assembly Examinations80Examinations o

21、f Hawaiian Airlines? Jackscrew Assemblies81Examinations of Alaska Airlines Reports of Acme Screw ?Wobble?831.16.7 Chemical and Microscopic Analyses of Grease Residues from the AccidentJackscrew Assembly841.16.8 Additional Grease Testing, Experiments, and Analysis851.16.8.11.16.8.2Standardized Grease

22、 Testing85Experiments and Analysis on the Surface Chemistry of AcmeNut Material When Exposed to Various Greases or Grease Mixtures85Wear Testing Under Various Grease Conditions861.16.8.31.17 Organizational and Management Information871.17.1 Alaska Airlines, Inc.871.17.2 Alaska Airlines Flight Crew T

23、raining881.17.2.11.17.2.21.17.2.3Stabilizer Trim Check Procedures88Runaway Stabilizer Checklist Procedures89Stabilizer Inoperative Checklist Procedures911.17.2.3.1Postaccident Boeing Flight Operations Bulletin on StabilizerTrim Inoperative/Malfunction Procedures921.17.3 FAA Oversight of Alaska Airli

24、nes931.17.3.1 General93ContentsvAircraft Accident Report1.17.3.21.17.3.3Preaccident FAA National Aviation Safety Inspection Program Inspection93FAA Air Transportation Oversight System931.17.3.3.1Seattle CMO Memorandum on Staff Shortages for Surveillanceof Alaska Airlines941.17.3.4 FAA Postaccident S

25、pecial Inspection of Alaska Airlines951.17.3.4.1FAA Proposed Suspension of Alaska Airlines? Heavy MaintenanceAuthority981.17.3.4.21.17.3.4.31.17.3.4.4Alaska Airlines Airworthiness and Operationion Plan99FAA Followup Evaluation100DOT Office of the Inspector General Report on FAA Oversightof Continuin

26、g Analysis and Surveillance Programs1021.17.4 Other Safety Evaluations of Alaska Airlines1031.17.4.11.17.4.21.17.4.3DoD Capability Survey of Alaska Airlines103Criminal Investigation of Alaska Airlines104Postaccident Independent Safety Assessment of Alaska Airlines1041.18 Additional Information1051.1

27、8.1 Postaccident Airworthiness Directives1051.18.1.1 Safety Board and FAA Correspondence Regarding the 2,000-Flight-HourEnd Play Check Interval Specified in ADs 2000-03-51 and 2000-15-151061.18.21.18.3Safety Board Statistical End Play Data Study108Previous Safety Recommendations Resulting from the A

28、laska AirlinesFlight 261 Investigation110Alaska Airlines Fleetwide MD-80 Jackscrew Assembly Data and TrackingHistory1131.18.41.18.51.18.61.18.7MD-11 Jackscrew Assembly Act Wear History116Safety Board Observations of Jackscrew Assembly Lubrications116End Play Check Anomalies1171.18.7.1 Safety Board E

29、nd Play Check Observations1171.18.7.2 Postaccident Alaska Airlines-Reported Near-Zero End Play Measurements1181.18.8 Jackscrew Assembly Overhaul Information1191.18.8.11.18.8.21.18.8.31.18.8.4Jackscrew Overhaul Specifications and Authority119Review of the Boeing DC-9 Overhaul Maintenance Manual120Saf

30、ety Board Maintenance Facility Observations121Overhauled Jackscrew Assembly Data From 1996 to 19991221.18.9 Industrywide Jackscrew Assembly Maintenance Procedures1221.18.10 FAA Commercial Airplane Certification Process Study1231.18.11 Fail-Safe Jackscrew Assembly Designs1252. Analysis1262.1 General1

31、262.2 Accident Sequence1272.2.12.2.2Takeoff and Climbout127Jamof the Horizontal Stabilizer1272.2.2.1Cause of the Jam1292.2.3Release of the Jam and the Initial Dive132The Second and Final Dive133Flight Crew Decision-Making135Decision to Continue Flying Rather than Return to PVR135Use of the Autopilot

32、137Configuration Changes1382.2.42.2.52.2.5.12.2.5.22.2.5.3ContentsviAircraft Accident Report2.2.5.42.2.5.5Activation of the Primary Trim Motor.138Adequacy of Current Guidance1392.3Evaluation of Potential Reasons for Excessive Act ThWear1402.3.12.3.22.3.32.3.42.3.5Use of Aeroshell 33 for Lubrication

33、of the Jackscrew Assembly141Acme Screw ThSurface Finish142Foreign Debris142Abnormal Loading of the Act Ths143Summary of Possibilities Ruled Out as Reasons for the Excessive AcmeNut ThWear1432.3.6Insufficient Lubrication of the Jackscrew Assembly1442.3.6.1Analysis of How Many Recently Scheduled Lubri

34、cations Might HaveBeen Missed or Inadequately Performed Before the Accident1462.3.6.2Alaska Airlines? Lubrication Interval Extension1462.3.6.2.1Safety Implications of Lubrication Interval Extension1472.3.6.3Adequacy of Lubrication Procedures1482.4Monitoring Act ThWear1512.4.1Alaska Airlines? Preacci

35、dent End Play Check Intervals1512.4.1.1Adequacy of Existing Process for Establishing Maintenance Task Intervals . . 1532.4.2Adequacy of Current End Play Check Intervals154Adequacy of End Play Check Procedure1562.4.32.5 Deficiencies of Jackscrew Assembly Overhaul Procedures and Practices1592.6 Horizo

36、ntal Stabilizer Trim System Design and Certification Issues1622.6.12.6.22.6.32.6.4Act ThLoss as a Catastrophic Single-Point Failure Mode162Prevention of Act ThLoss Through Maintenance and Inspection165Elimination of Catastrophic Effects of Act ThLoss Through Design . 166Consideration of Wear-Related

37、 Failures During Design and Certification1672.7Deficiencies in Alaska Airlines? Maintenance Program1672.7.12.7.2April 2000 FAA Special Inspection Findings167Maintenance-Related Deficiencies Identified During This AccidentInvestigation1692.7.2.1 General Policy Decisions1692.7.2.2 Specific Maintenance

38、 Actions1722.7.3Summary1742.8FAA Oversight1743.s176Findings176Probable Cause1803.13.24. Recommendations1814.1 New Recommendations1814.2 Previously Issued Recommendations Resulting From This Accident Investigation184Board Member Statements1875. Appendixes190viiAircraft Accident ReportFigures1.The acc

39、ident airplane?s flightpath, starting about 1609 (about the time of the initial dive)and ending about 1620 (about the time of the second and final dive).52.Radar altitude data and selected ATC transmissions from about 1609 to 162063.Installation of jackscrew assembly within the horizontal and vertic

40、al stabilizers. . . . . . . . . . . . . . . .134.The MD-80 horizontal and vertical stabilizer tail structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145.Acme screw and nut. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41、 . . . . . . . . . .156.ed schematic of the longitudinal trim actuating mechanism. . . . . . . . . . . . . . . . . . . . . . . . . . .167.Cockpit switches, handles, and indicators for the longitudinal control system. . . . . . . . . . . . . . . . . .178.Depiction of how restraining fixture should be

42、 placed on the horizontal stabilizer during anend play check. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .409.View of a typical dial indicator set up for end play checks. . . . . . . . . . . . . . . . . . . . . .

43、. . . . . . . . . . .4110.Two Alaska Airlines-fabricated restraining fixtures and three Boeing- manufactured fixtures. . . . .4611.The September 27, 1997, MIG-4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5112a.The acme screw immediately af

44、ter it was brought on board the recovery ship . . . . . . . . . . . . . . . . .5912b.The acme screw immediately after it was brought to shore6012c.The acme screw during initial inspection.6113.A photograph of the acme screw thremnants wrapped around the screw, the red rustareas, and the white deposi

45、ts.6814.A photograph of the sand/grease mixture packed between the acme screw?s lower ths.6915.A photograph of an overall view of the recovered act assembly7316.A photograph of ar view of the interior of the act.7317.A diagram of a cross-section through the act?s grease passageway and fitting. Red a

46、reasdenote the locations where red grease was found, and gray areas denote the location where thedry residue was found.7418.A photograph of the grease passageway and counterbore after the act was sectioned.75FiguresviiiAircraft Accident Report19. A summary of the results of the high-load wear tests,

47、 including the contaminationand low-temperature tests.8720. A graphical depiction of the stages of act thwear to the point of fracture.131ixAircraft Accident ReportAbbreviationsAC AD ALPA AMFA AOLARTCC ASB ATC ATOS ATP CAM CAR CFR CG CMO CMR CSP CVR DFDoD DOT EDS E.O. FAA FARsFDRadvisory circular ai

48、rworthiness directiveAir Line Pilots AssociationAircraft Mechanics Fraternal Association all operators letterAir Route Traffic Control Center alert service bulletinair traffic controlAir Transportation Oversight System airline transport pilotcockpit area microphone Civil Aeronautics Regulations Code

49、 of Federal Regulations center of gravityManagement Officecertification maintenance requirementcompensive surveillance plancockpit voice recorderigital flight guidance computer Department of Defense Department of Transportation(x-ray) energy dispersive spectroscopy engineering orderFederal Aviation

50、AdministrationFederal Aviation Regulationsflight data recorderAbbreviationsxAircraft Accident ReportFEA FL FSAW FSDOFtu GMM KIASLAXfinite element analysis flight levelFlight Standards Information Bulletin for Airworthiness Flight Standards District Officeminimum ultimate strength General Maintenance

51、 Manual knots indicated airspeedLosAngelesInternationalAirport,LosAngeles,Californiamean aerodynamic chordMaintenance Review Board Maintenance Steering GroupMAC MRB MSG MSI MTBR MTBUR NASIP OAK OAMP OJTP/N PMIpsi PST PTRSPVRmaintenance significtemmemebetween removalbetween unscheduled removalNationa

52、l Aviation Safety Inspection Program Oakland International Airport, Oakland, California on-aircraft maintenance planningon-the-job training part numberprincipal maintenance inspector pounds per square inchPacific standard timeProgram Tracking and Reporting SystemLic Gustavo Diaz Ordaz International

53、Airport, Puerto Vallarta, MexicoQuick Reference Handbook root mean squaredserial numberSociety of Automotive EngineersQRH RMSS/NSAEAbbreviationsxiAircraft Accident ReportSBSEAservice bulletinSeattle-Tacoma WashingtonInternationalAirport,Seattle,SEMSFOscanning electron microscopySan Frsco Internation

54、al Airport, San Fr Californiaunified numbering systemsco,UNSxiiAircraft Accident ReportExecutive SummaryOn January 31, 2000, about 1621 Pacific standard time, Alaska Airlines, Inc., flight 261, a McDonnell Douglas MD-83, N963AS, crashed into the Pacific Ocean about2.7north of Anacapa Island, Califor

55、nia. The 2 pilots, 3 cabin crewmembers, and83 passengers on board were killed, and the airplane was destroyed by impact forces. Flight 261 was operating as a scheduled international passenger flight under the provisions of 14 Code of Federal Regulations Part 121 from Lic Gustavo Diaz Ordaz International Airport, Puerto Vallarta, Mexico, to Seattle-Tacoma International Airport,Seattle, Washington, with an intermediate stop planned at San Frsco InternationalAirport, San Frsco, California. Visual meteorolo