What happened
The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.
Narrative: American eagle (simmons airlines-sima), flight 4253 IG3197019 an aerospatiale ATR-72, aircraft serial number 438, registration number N438AT, operating as American eagle flight 4253, landed at o'hare airport, chicago, Illinois at approximately 1725Z 10/11/97 with the left nose tire missing. Tvc (Traverse City, MI) ATCT reported seeing the front wheel and tire fall off on departure at 1612Z. Aircraft continued to ord and at 1714Z a fly-by at ord showed one wheel to be missing and the other appeared to be down and locked. Acft landed without incident. Emergency equipment was standing by. Passengers were deplaned through the normal passenger entry door at the rear of the aircraft on the runway and bused to the terminal. Aircraft was inspected and pictures were taken by the FAA, NTSB and a sima maintenance manager at the American eagle hangar with the following finding. The nose landing gear strut was found with the left axle cleaned of grease and all hardware was missing (no mount bolts, nuts, and spacers etc.). Maintenance stated that there was grease on the axle but was cleaned off before the inspector arrived. A visual inspection showed no damage to the axle. The right nose wheel (installed at the same time as the left) was inspected and was found with the lock axle bolt nut cotter key installed improperly. The cotter key was loose and did not pass through the castellation of the nut. The prongs (end of the cotter key); top prong was not up and back over the end of the bolt and the bottom prong did not go straight down to the bottom of the nut. The cotter key was bent around the threads of the bolt. Further inspection revealed that the nut that was installed (the lock axle bolt nut) was not what was called for in the atr mm and ipc. This was a non self locking nut that was installed. The manufacturer requires a self locking nut per the ipc 32-21-11 item 30 part number MS17825-3 and described in the atr mm jic (job instruction cards) 12-37-32 page 4 item 6 note: also in 1991 a service bulletin (s.b. ATR42-32-0030) was issued for the atr 42 addressing the nose wheel, axle nuts and spacer. Sima's issued an engineering order e.o. 4-32-022(e.o. attached). This s.b. and e.o. changed the nut to the present castellated self locking nut. The atr 72 has this same requirement. The NTSB representative concluded that this shows a failure to follow a manual. Investigation was turned over to the FAA. Both of these wheels assemblies were changed on sep 11, 1997 by sima ord maintenance. Reviewed the non-routine card and the component control tags for the nose wheel changes. Sima's maintenance manager revealed that employee number 482644, MS. Jennifer street changed both the nose wheels on sep. 11, 1997. On the day of the incident (oct. 11, 1997) sima's maintenance manager informed the FAA that a special inspection will be performed to check that the proper hardware is installed on the nose wheel assemblies on the other sima aircraft (a spot inspection was accomplished on oct. 16, 1997 report attached). Inspectors from the chicago flight standard district office (ord-fsdo) interviewed the mechanic on oct. 14, 1997, the mechanic stated that both tires were changed by her and all work was accomplished per the mm jic 12-37-32 and the parts used were correct parts, per the ipc. (Record of conversation attached). Sima's investigation revealed that no other work was performed on the nose wheels since the nose wheel changes on sep. 11, 1997. Contacted the grand rapids FSDO. Inspector calabrese reported the tvc (Traverse City) sima station only found the wheel assembly and no other hardware was found. The pmi was briefed. A package was sent to the cmu and received containing the documentation, pictures and the improper hardware removed from the right wheel assemble of N438AT. An enforcement investigative report is being processed by the sima cmu. File:10-igsim. Doc follow up to incident American eagle (simmons airlines-sima), 10/11/97 report IGL3197019. An aerospatiale ATR-72, aircraft serial number 438, registration number N438AT, operating as American eagle flight 4253, landed at o'hare airport, chicago, Illinois at approximately 1725Z 10/11/97 with the left nose tire missing. The right nose wheel (installed at the same time as the left) was inspected and was found with the lock axle bolt nut cotter key installed improperly. The cotter key was loose and did not pass through the castellation of the nut. The prongs (end of the cotter key); top prong was not up and back over the end of the bolt and the bottom prong did not go straight down to the bottom of the nut. The cotter key was bent around the threads of the bolt. Further inspection revealed that the nut that was installed (the lock axle bolt nut) was not what was called for in the atr mm and ipc. This was a non self locking nut that was installed. The manufacturer requires a self locking nut per the ipc 32-21-11 item 30 part number MS17825-3 and described in the mm jic (job instruction cards) 12-37-32 page 4 item 6 note: on oct 16, 1997 a follow up inspection of the nose wheel lock bolt hardware was completed on 7 (seven) sima (atr) aircraft. Inspector found on aircraft N414WF the nose wheel lock bolt missing the washer, a requirement of the atr maintenance manual. A spot inspection was completed to observe the operation and installation of the lock bolt. With the following results 1. Maintenance could not find the job instruction guide normally kept on the line, information had to be sent from the hangar. 2. The proper torque wrench could not be located and again a torque wrench had to come from the hangar. 3. This task took close to 2 hours to complete from the time of discovery. File: 10-igsim. Doc
As the FAA filed it
NARRATIVE: AMERICAN EAGLE (SIMMONS AIRLINES-SIMA), FLIGHT 4253 IG3197019 AN AEROSPATIALE ATR-72, AIRCRAFT SERIAL NUMBER 438, REGISTRATION NUMBER N438AT, OPERATING AS AMERICAN EAGLE FLIGHT 4253, LANDED AT O'HARE AIRPORT, CHICAGO, ILLINOIS AT APPROXIMATELY 1725Z 10/11/97 WITH THE LEFT NOSE TIRE MISSING. TVC (TRAVERSE CITY, MI) ATCT REPORTED SEEING THE FRONT WHEEL AND TIRE FALL OFF ON DEPARTURE AT 1612Z. AIRCRAFT CONTINUED TO ORD AND AT 1714Z A FLY-BY AT ORD SHOWED ONE WHEEL TO BE MISSING AND THE OTHER APPEARED TO BE DOWN AND LOCKED. ACFT LANDED WITHOUT INCIDENT. EMERGENCY EQUIPMENT WAS STANDING BY. PASSENGERS WERE DEPLANED THROUGH THE NORMAL PASSENGER ENTRY DOOR AT THE REAR OF THE AIRCRAFT ON THE RUNWAY AND BUSED TO THE TERMINAL. AIRCRAFT WAS INSPECTED AND PICTURES WERE TAKEN BY THE FAA, NTSB AND A SIMA MAINTENANCE MANAGER AT THE AMERICAN EAGLE HANGAR WITH THE FOLLOWING FINDING. THE NOSE LANDING GEAR STRUT WAS FOUND WITH THE LEFT AXLE CLEANED OF GREASE AND ALL HARDWARE WAS MISSING (NO MOUNT BOLTS, NUTS, AND SPACERS ETC.). MAINTENANCE STATED THAT THERE WAS GREASE ON THE AXLE BUT WAS CLEANED OFF BEFORE THE INSPECTOR ARRIVED. A VISUAL INSPECTION SHOWED NO DAMAGE TO THE AXLE. THE RIGHT NOSE WHEEL (INSTALLED AT THE SAME TIME AS THE LEFT) WAS INSPECTED AND WAS FOUND WITH THE LOCK AXLE BOLT NUT COTTER KEY INSTALLED IMPROPERLY. THE COTTER KEY WAS LOOSE AND DID NOT PASS THROUGH THE CASTELLATION OF THE NUT. THE PRONGS (END OF THE COTTER KEY); TOP PRONG WAS NOT UP AND BACK OVER THE END OF THE BOLT AND THE BOTTOM PRONG DID NOT GO STRAIGHT DOWN TO THE BOTTOM OF THE NUT. THE COTTER KEY WAS BENT AROUND THE THREADS OF THE BOLT. FURTHER INSPECTION REVEALED THAT THE NUT THAT WAS INSTALLED (THE LOCK AXLE BOLT NUT) WAS NOT WHAT WAS CALLED FOR IN THE ATR MM AND IPC. THIS WAS A NON SELF LOCKING NUT THAT WAS INSTALLED. THE MANUFACTURER REQUIRES A SELF LOCKING NUT PER THE IPC 32-21-11 ITEM 30 PART NUMBER MS17825-3 AND DESCRIBED IN THE ATR MM JIC (JOB INSTRUCTION CARDS) 12-37-32 PAGE 4 ITEM 6 NOTE: ALSO IN 1991 A SERVICE BULLETIN (S.B. ATR42-32-0030) WAS ISSUED FOR THE ATR 42 ADDRESSING THE NOSE WHEEL, AXLE NUTS AND SPACER. SIMA'S ISSUED AN ENGINEERING ORDER E.O. 4-32-022(E.O. ATTACHED). THIS S.B. AND E.O. CHANGED THE NUT TO THE PRESENT CASTELLATED SELF LOCKING NUT. THE ATR 72 HAS THIS SAME REQUIREMENT. THE NTSB REPRESENTATIVE CONCLUDED THAT THIS SHOWS A FAILURE TO FOLLOW A MANUAL. INVESTIGATION WAS TURNED OVER TO THE FAA. BOTH OF THESE WHEELS ASSEMBLIES WERE CHANGED ON SEP 11, 1997 BY SIMA ORD MAINTENANCE. REVIEWED THE NON-ROUTINE CARD AND THE COMPONENT CONTROL TAGS FOR THE NOSE WHEEL CHANGES. SIMA'S MAINTENANCE MANAGER REVEALED THAT EMPLOYEE NUMBER 482644, MS. JENNIFER STREET CHANGED BOTH THE NOSE WHEELS ON SEP. 11, 1997. ON THE DAY OF THE INCIDENT (OCT. 11, 1997) SIMA'S MAINTENANCE MANAGER INFORMED THE FAA THAT A SPECIAL INSPECTION WILL BE PERFORMED TO CHECK THAT THE PROPER HARDWARE IS INSTALLED ON THE NOSE WHEEL ASSEMBLIES ON THE OTHER SIMA AIRCRAFT (A SPOT INSPECTION WAS ACCOMPLISHED ON OCT. 16, 1997 REPORT ATTACHED). INSPECTORS FROM THE CHICAGO FLIGHT STANDARD DISTRICT OFFICE (ORD-FSDO) INTERVIEWED THE MECHANIC ON OCT. 14, 1997, THE MECHANIC STATED THAT BOTH TIRES WERE CHANGED BY HER AND ALL WORK WAS ACCOMPLISHED PER THE MM JIC 12-37-32 AND THE PARTS USED WERE CORRECT PARTS, PER THE IPC. (RECORD OF CONVERSATION ATTACHED). SIMA'S INVESTIGATION REVEALED THAT NO OTHER WORK WAS PERFORMED ON THE NOSE WHEELS SINCE THE NOSE WHEEL CHANGES ON SEP. 11, 1997. CONTACTED THE GRAND RAPIDS FSDO. INSPECTOR CALABRESE REPORTED THE TVC (TRAVERSE CITY) SIMA STATION ONLY FOUND THE WHEEL ASSEMBLY AND NO OTHER HARDWARE WAS FOUND. THE PMI WAS BRIEFED. A PACKAGE WAS SENT TO THE CMU AND RECEIVED CONTAINING THE DOCUMENTATION, PICTURES AND THE IMPROPER HARDWARE REMOVED FROM THE RIGHT WHEEL ASSEMBLE OF N438AT. AN ENFORCEMENT INVESTIGATIVE REPORT IS BEING PROCESSED BY THE SIMA CMU. FILE:10-IGSIM.DOC FOLLOW UP TO INCIDENT AMERICAN EAGLE (SIMMONS AIRLINES-SIMA), 10/11/97 REPORT IGL3197019. AN AEROSPATIALE ATR-72, AIRCRAFT SERIAL NUMBER 438, REGISTRATION NUMBER N438AT, OPERATING AS AMERICAN EAGLE FLIGHT 4253, LANDED AT O'HARE AIRPORT, CHICAGO, ILLINOIS AT APPROXIMATELY 1725Z 10/11/97 WITH THE LEFT NOSE TIRE MISSING. THE RIGHT NOSE WHEEL (INSTALLED AT THE SAME TIME AS THE LEFT) WAS INSPECTED AND WAS FOUND WITH THE LOCK AXLE BOLT NUT COTTER KEY INSTALLED IMPROPERLY. THE COTTER KEY WAS LOOSE AND DID NOT PASS THROUGH THE CASTELLATION OF THE NUT. THE PRONGS (END OF THE COTTER KEY); TOP PRONG WAS NOT UP AND BACK OVER THE END OF THE BOLT AND THE BOTTOM PRONG DID NOT GO STRAIGHT DOWN TO THE BOTTOM OF THE NUT. THE COTTER KEY WAS BENT AROUND THE THREADS OF THE BOLT. FURTHER INSPECTION REVEALED THAT THE NUT THAT WAS INSTALLED (THE LOCK AXLE BOLT NUT) WAS NOT WHAT WAS CALLED FOR IN THE ATR MM AND IPC. THIS WAS A NON SELF LOCKING NUT THAT WAS INSTALLED. THE MANUFACTURER REQUIRES A SELF LOCKING NUT PER THE IPC 32-21-11 ITEM 30 PART NUMBER MS17825-3 AND DESCRIBED IN THE MM JIC (JOB INSTRUCTION CARDS) 12-37-32 PAGE 4 ITEM 6 NOTE: ON OCT 16, 1997 A FOLLOW UP INSPECTION OF THE NOSE WHEEL LOCK BOLT HARDWARE WAS COMPLETED ON 7 (SEVEN) SIMA (ATR) AIRCRAFT. INSPECTOR FOUND ON AIRCRAFT N414WF THE NOSE WHEEL LOCK BOLT MISSING THE WASHER, A REQUIREMENT OF THE ATR MAINTENANCE MANUAL. A SPOT INSPECTION WAS COMPLETED TO OBSERVE THE OPERATION AND INSTALLATION OF THE LOCK BOLT. WITH THE FOLLOWING RESULTS 1. MAINTENANCE COULD NOT FIND THE JOB INSTRUCTION GUIDE NORMALLY KEPT ON THE LINE, INFORMATION HAD TO BE SENT FROM THE HANGAR. 2. THE PROPER TORQUE WRENCH COULD NOT BE LOCATED AND AGAIN A TORQUE WRENCH HAD TO COME FROM THE HANGAR. 3. THIS TASK TOOK CLOSE TO 2 HOURS TO COMPLETE FROM THE TIME OF DISCOVERY. FILE: 10-IGSIM.DOC
Other reports on N438AT · 3
Matched to the same aircraft by N-number and date.