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Leading Edge Device Failure Norfolk Island 29 December 2007 VH-OBN, Boeing 737-229

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Leading Edge Device Failure Norfolk Island 29 December 2007 VH-OBN, Boeing 737-229 VH-OBN, Boeing 737-229 VH-OBN, Island, 29 December 2007, failure, Norfolk device Leading edge ATSB TRANSPORT SAFETY REPORT Occurrence Investigation Report AO-2007-070 Final Leading edge device failure Norfolk Island 29 December 2007 VH-OBN, Boeing 737-229 ATSB TRANSPORT SAFETY REPORT Aviation Occurrence Investigation AO-2007-070 Final Leading edge device failure Norfolk Island 29 December 2007 VH-OBN, Boeing Company 737-229 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 - i - Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office location: 62 Northbourne Ave, Canberra City, Australian Capital Territory Telephone: 1800 020 616; from overseas + 61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117; from overseas + 61 2 6247 3117 E-mail: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2010. This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this material in unaltered form (retaining this notice). However, copyright in the material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau. Please direct requests for further information or authorisation to: Commonwealth Copyright Administration, Copyright Law Branch Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 www.ag.gov.au/cca ISBN and formal report title: see ‘Document retrieval information’ on page vi. - ii - CONTENTS THE AUSTRALIAN TRANSPORT SAFETY BUREAU ............................... vii TERMINOLOGY USED IN THIS REPORT ................................................. viii FACTUAL INFORMATION.............................................................................. 1 History of the flight........................................................................................ 1 Preparation of the cabin for ditching................................................... 2 Flight planning ................................................................................... 3 Injuries to persons .......................................................................................... 4 Damage to aircraft ......................................................................................... 4 Leading edge flap/slat system............................................................. 4 Number-4 slat examination ................................................................ 5 Personnel information .................................................................................... 7 Flight crew......................................................................................... 7 Cabin crew......................................................................................... 8 Aircraft information ....................................................................................... 9 Meteorological information ............................................................................ 9 Communications ............................................................................................ 9 Aerodrome information ................................................................................ 10 Recorded information .................................................................................. 10 Departure from Brisbane .................................................................. 10 Approach to Norfolk Island .............................................................. 11 Missed approach .............................................................................. 11 Cockpit voice recorder ..................................................................... 11 Survival aspects ........................................................................................... 12 Cabin crew procedures ..................................................................... 12 Able bodied passengers .................................................................... 13 Lifejackets13 Public address system ...................................................................... 14 Tests and research ........................................................................................ 15 Organisational and management information................................................ 15 Aircraft operator .............................................................................. 15 Post-incident response by the operator.............................................. 16 ANALYSIS ........................................................................................................ 17 Introduction ................................................................................................. 17 - iii - Approach to Nouméa ................................................................................... 17 Weather 17 Crew actions .................................................................................... 18 Leading edge slat failure .............................................................................. 18 Number-4 leading edge slat main track............................................. 18 Number-4 leading edge slat auxiliary tracks ..................................... 19 Survival factors ............................................................................................ 19 Briefing of passengers ...................................................................... 20 Cabin crew role confusion ................................................................ 20 Public address system ...................................................................... 20 Post-occurrence operator actions ...................................................... 21 FINDINGS ......................................................................................................... 23 Contributing safety factors ........................................................................... 23 Other safety factors ...................................................................................... 23 Other key findings ....................................................................................... 23 SAFETY ACTIONS .......................................................................................... 25 Aircraft operator .......................................................................................... 25 Difficulty using the emergency procedures cards .............................. 25 Crew resumption of operations ......................................................... 25 Other safety action ........................................................................... 26 NOTE FOR WEBSITE REGARDING ANIMATIONS .................................. 27 APPENDIX A: SUMMARY OF PASSENGER SURVEY............................... 29 Respondents’ perception of the problem ....................................................... 29 Preparation for the possible ditching ............................................................ 29 Passenger seating & exit row briefings ............................................. 30 Lifejackets31 Passenger announcements ................................................................ 31 Children 31 Passenger needs ........................................................................................... 32 Passenger injuries ........................................................................................ 32 APPENDIX B: TECHNICAL ANALYSIS REPORT ...................................... 35 FACTUAL INFORMATION ....................................................................... 36 Introduction ..................................................................................... 36 Scope 36 Leading-edge slat overview .............................................................. 36 Main track examination.................................................................... 38 - iv - Microscopy ...................................................................................... 42 Hardness testing ............................................................................... 45 Dimensional inspection .................................................................... 45 Magnetic particle inspection............................................................. 45 Auxiliary tracks ............................................................................... 45 ANALYSIS ................................................................................................. 49 FINDINGS .................................................................................................. 50 APPENDIX C: SEQUENCE OF EVENTS FROM THE DFDR DATA ......... 51 APPENDIX D: GRAPHICAL REPRESENTATION OF DFDR DATA ........ 53 APPENDIX E: SOURCES AND SUBMISSIONS ............................................ 55 - v - DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN AO-2007-070 8 February 2010 64 978-1-74251-030-9 Publication title Leading edge device failure - Norfolk Island - 29 December 2007 - VH-OBN, Boeing 737-229 Prepared by Reference No. Australian Transport
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