Atlanta - Dallas
Flight / Schedule
Atlanta - Dallas
Aircraft
Boeing 737-200Registration
EI-CJW
MSN
21355
Year of Manufacture
1977
Operator
Airtran AirwaysDate
November 1, 1998 at 06:48 PM
Type
CRASHFlight Type
Scheduled Revenue Flight
Flight Phase
Landing (descent or approach)
Crash Site
Airport (less than 10 km from airport)
Crash Location
Atlanta-William Berry Hartsfield Georgia
Region
North America • United States of America
Crash Cause
Human factor
Narrative Report
On November 1, 1998 at 06:48 PM, Atlanta - Dallas experienced a crash involving Boeing 737-200, operated by Airtran Airways, with the event recorded near Atlanta-William Berry Hartsfield Georgia.
The flight was categorized as scheduled revenue flight and the reported phase was landing (descent or approach) at a airport (less than 10 km from airport) crash site.
105 people were known to be on board, 0 fatalities were recorded, 105 survivors were identified or estimated. This corresponds to an estimated fatality rate of 0.0%.
Crew on board: 5, crew fatalities: 0, passengers on board: 100, passenger fatalities: 0, other fatalities: 0.
The listed crash cause is human factor. The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine of the Boeing 737-200 during a postflight inspection at William B. Hartsfield Atlanta International Airport (ATL), Georgia. AirTran mechanics at ATL identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. They found the part in the illustrated parts catalog (IPC), which was not designed as a troubleshooting document and does not contain sufficient detail for such use. One of the mechanics telephoned an AirTran maintenance controller in Orlando, Florida, for further instructions. The mechanics who initially identified the source of the leak had little experience working on the Boeing 737 because they had worked for ValuJet Airlines, which flew DC-9s only, until ValuJet and AirTran merged in September 1997. On the basis of the information provided by the mechanic, and without questioning his description of the line or verifying the part number that he had provided against the IPC or some other appropriate maintenance document, the maintenance controller instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. Depletion of system A hydraulic fluid activated the hydraulic low-pressure lights in the cockpit, which alerted the flight crew that the airplane had a hydraulic problem. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch.
Aircraft reference details include registration EI-CJW, MSN 21355, year of manufacture 1977.
Fatalities
Total
0
Crew
0
Passengers
0
Other
0
Crash Summary
The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine of the Boeing 737-200 during a postflight inspection at William B. Hartsfield Atlanta International Airport (ATL), Georgia. AirTran mechanics at ATL identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. They found the part in the illustrated parts catalog (IPC), which was not designed as a troubleshooting document and does not contain sufficient detail for such use. One of the mechanics telephoned an AirTran maintenance controller in Orlando, Florida, for further instructions. The mechanics who initially identified the source of the leak had little experience working on the Boeing 737 because they had worked for ValuJet Airlines, which flew DC-9s only, until ValuJet and AirTran merged in September 1997. On the basis of the information provided by the mechanic, and without questioning his description of the line or verifying the part number that he had provided against the IPC or some other appropriate maintenance document, the maintenance controller instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. Depletion of system A hydraulic fluid activated the hydraulic low-pressure lights in the cockpit, which alerted the flight crew that the airplane had a hydraulic problem. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch.
Cause: Human factor
Occupants & Outcome
Crew On Board
5
Passengers On Board
100
Estimated Survivors
105
Fatality Rate
0.0%
Known people on board: 105
Operational Details
Schedule / Flight
Atlanta - Dallas
Operator
Airtran AirwaysFlight Type
Scheduled Revenue Flight
Flight Phase
Landing (descent or approach)
Crash Site
Airport (less than 10 km from airport)
Region / Country
North America • United States of America
