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Runway Departure During Attempted Takeoff, Tower Air Flight 41, Boeing

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Runway Departure During Attempted Takeoff, Tower Air Flight 41, Boeing PB96-910404 NTSB/AAR-96/04 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE DURING ATTEMPTED TAKEOFF TOWER AIR FLIGHT 41 BOEING 747-136, N605FF JFK INTERNATIONAL AIRPORT, NEW YORK DECEMBER 20,1995 6671A The 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 transportation 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 its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)314-6551 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSB/AAR-96/04 PB96-910404 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE DURING ATTEMPTED TAKEOFF TOWER AIR FLIGHT 41 BOEING 747-136, N605FF JFK INTERNATIONAL AIRPORT, NEW YORK DECEMBER 20, 1995 Adopted: December 2, 1996 Notation 6671A Abstract: This report explains the runway departure during attempted takeoff of Tower Air flight 41, N605FF, a Boeing 747-136 at John F. Kennedy International Airport, New York, on December 20, 1995. The safety issues discussed in this report include the adequacy of Boeing and air carrier procedures for B-747 operations on slippery runways; adequacy of flight simulators for training B-747 pilots in slippery runway operations; security of galley equipment installed on transport category aircraft; role of communications among flight attendants and between the cabin crew and the flightcrew; adequacy of Tower Air galley security training; compliance of Tower Air’s maintenance department with its established procedures; failure of the FDR system to function during the accident; adequacy of the Tower Air operational management structure; adequacy of FAA surveillance and workload imposed on POIs; adequacy of runway friction measurement requirements, including correlation of runway friction measurements with aircraft braking and ground handling performance. Safety recommendations concerning these issues were made to the Federal Aviation Administration (FAA) and Tower Air, Inc. CONTENTS EXECUTIVE SUMMARY_____________________________________________________ vii 1. FACTUAL INFORMATION _________________________________________________ 1 1.1 History of Flight _______________________________________________________________ 1 1.2 Injuries to Persons _____________________________________________________________ 4 1.3 Damage to Airplane ____________________________________________________________ 4 1.4 Other Damage ________________________________________________________________ 5 1.5 Personnel Information__________________________________________________________ 5 1.5.1 The Captain_______________________________________________________________________ 5 1.5.2 First Officer_______________________________________________________________________ 5 1.5.3 Flight Engineer ____________________________________________________________________ 6 1.6 Airplane Information___________________________________________________________ 6 1.6.1 General __________________________________________________________________________ 6 1.6.2 Maintenance Records Review_________________________________________________________ 7 1.7 Meteorological Information ____________________________________________________ 10 1.8 Aids to Navigation ____________________________________________________________ 11 1.9 Communications______________________________________________________________ 11 1.10 Airport Information__________________________________________________________ 11 1.10.1 General ________________________________________________________________________ 11 1.10.2 Runway Conditions_______________________________________________________________ 11 1.10.3 Previous Safety Board Recommendations _____________________________________________ 13 1.10.4 Air Carrier Slippery Runway Events__________________________________________________ 14 1.11 Flight Recorders_____________________________________________________________ 14 iii 1.11.1 Flight Data Recorder______________________________________________________________ 14 1.11.2 Cockpit Voice Recorder ___________________________________________________________ 14 1.12 Wreckage and Impact Information _____________________________________________ 15 1.13 Medical and Pathological Information __________________________________________ 17 1.14 Fire________________________________________________________________________ 17 1.15 Survival Aspects _____________________________________________________________ 17 1.15.1 Cabin Interior Layout and Damage___________________________________________________ 17 1.15.2 Galley Equipment Description ______________________________________________________ 19 1.15.3 Flight Attendant Galley Preflight Procedures ___________________________________________ 22 1.15.4 Flight Attendant Galley Preflight Activities ____________________________________________ 22 1.15.5 Events in the Cabin During the Accident Sequence ______________________________________ 23 1.15.6 Deplanement ____________________________________________________________________ 24 1.15.7 Flight Attendant Training __________________________________________________________ 24 1.16 Tests and Research___________________________________________________________ 26 1.16.1 Flight Recorder Tests _____________________________________________________________ 26 1.16.2 Cockpit Voice Recorder Sound Spectral Study _________________________________________ 27 1.17 Organizational and Management Information____________________________________ 27 1.17.1 Reporting Relationships Among Operational Managers___________________________________ 27 1.17.2 Director of Flight Safety ___________________________________________________________ 29 1.18 Additional Information _______________________________________________________ 29 1.18.1 Operating Procedures - Boeing 747 __________________________________________________ 29 1.18.2 Flightcrew Training_______________________________________________________________ 31 1.18.3 Pilot Techniques for B-747 Takeoffs _________________________________________________ 32 1.18.4 B-747 Simulator Activity __________________________________________________________ 33 1.18.5 Recent Tower Air Accidents and Incidents_____________________________________________ 35 iv 1.18.6 FAA Surveillance ________________________________________________________________ 36 1.18.7 Aircraft Performance______________________________________________________________ 38 2. ANALYSIS_______________________________________________________________ 40 2.1 General _____________________________________________________________________ 40 2.2 Flightcrew Actions and Decisions________________________________________________ 40 2.2.1 Pre-takeoff Events_________________________________________________________________ 40 2.2.2 The Attempted Takeoff and Loss of Control ____________________________________________ 41 2.2.3 Timeliness of the Rejected Takeoff ___________________________________________________ 42 2.2.4 B-747 Slippery Runway Operating Procedures __________________________________________ 43 2.2.5 Training Simulators for B-747 Slippery Runway Operations ________________________________ 45 2.2.6 Summary of Flightcrew Actions and Decisions __________________________________________ 45 2.3 Galley Security _______________________________________________________________ 46 2.4 Flight Attendant Actions and Training ___________________________________________ 46 2.4.1 Flight Attendant Communication _____________________________________________________ 46 2.4.2 Flight Attendant CRM Training ______________________________________________________ 48 2.4.3 Flight Attendant Galley Training _____________________________________________________ 48 2.4.4 Purser Training ___________________________________________________________________ 48 2.5 Company Management ________________________________________________________ 49 2.5.1 Maintenance _____________________________________________________________________ 49 2.5.2 Operations_______________________________________________________________________ 51 2.6 FAA Surveillance _____________________________________________________________ 51 2.7 Runway Contamination Evaluation______________________________________________ 53 3. CONCLUSIONS __________________________________________________________ 55 3.1 Findings_____________________________________________________________________ 55 v 3.2 Probable Cause_______________________________________________________________ 57 4. RECOMMENDATIONS____________________________________________________ 58 5. APPENDIXES____________________________________________________________ 61 APPENDIX A - INVESTIGATION AND HEARING _______________________________ 61 1. Investigation
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