What happened
The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.
Boeing MD-11 N294UP incident Honolulu (hnl) 12/20/2017 0731Z [12/19/2017 2131 HST]
United parcel service airlines (ups) event report 65272; captain reporting;
?This report is actually a report of a level 2 anti-skid fail.
Stable approach hnl 04R. After the gear was extended and landing checklist was completed, level
2 "Anti-skid fail" message illuminated. F/o was pilot flying. I read [captain] what I thought was the appropriate
Checklist and called it complete. The touchdown was normal and when brakes were applied aircraft
Listed to the left as we came to a stop? Captain and first officer have
Both submitted asap reports.?
FAA investigation:
12/20 On approach the crew used ?autobrake fail? Checklist versus the correct checklist ?anti-skid fail?. Ups MD-11 quick reference handbook (qrh) procedures for the ?anti-skid fail? The crew should perform a go around and setup for the longest runway with higher degree of flaps. Crew used the ?autobrake fail? Checklist; select the auto brake selector to off and continue the landing.
Maintenance record review shows in a 27-DAY period prior to the incident, 12/20, the anti-skid system had failed on approach 7 times out of 52 flights. Prior 30-DAY history from 11/23, shows no anti-skid fail messages.
11/23, During taxi into ontario (ont) pilots received ?r anti-skid fail? Message. Maintenance performed the Boeing MD-11 fault isolation manual (fim) 32-40-12-00 and replaced the anti-skid control unit in accordance with aircraft maintenance manual (amm) 32-45-01.
Logbook pages (l/p) # 690302-2 (11/29); l/p# 690316-2 (12/03); and l/p# 733009-2 (12/09); all show a level 2 ?l anti-skid fail? Alert appeared on approach and/or landing. Logbook corrective actions were completed with no faults noted and only logbook page l/p# 690316, item 2, (12/03) referenced an amm test [anti-skid system task 32-45-00] as being accomplished. None of the l\p?s referenced show that maintenance personnel used the fault isolation manual (fim) to troubleshoot the anti-skid system.
12/11, Ups initiated an alert [ups general maintenance manual (gmm) 03.27.01], maintenance action item program. The alert plan was developed on 12/12 from ups MD-11 aircraft health monitoring system (ahms) and aircraft records. The tech recommends with a due date 12/19, ?replace the a/s valve system 3-valve 1 per amm 32-45-21/401. Old style valves have an alignment pin while new style does not.?
Ups MD-11 ahms is not FAA approved and/or accepted. Ups MD-11 ahms uses system data that is downloaded while the aircraft is in operation to assist in troubleshooting maintenance issues. The MD-11 fim is a maintenance manual designed to troubleshoot faults indicated by the central fault display system (cfds). On the ground and in the cockpit.
L/p# 687668-2 (12/16); l/p# 687671-2 (12/16); and l/p# 767361-2 (12/19); all show a level 2 ?l anti-skid fail? Appeared on approach during landing gear extension. Logbook corrective actions were completed with no faults noted and only the l\p dated 12/16 and 12/19 reference an amm test [anti-skid system task 32-45-00]. None of the l\p referenced show that maintenance personnel used the fim to troubleshoot the anti-skid system.
L/p dated: 12/20, day of incident, show the flight crew received a level 2 ?antiskid fail? Alert during gear extension. On landing 5 main landing gear (MLG) tires blew out, 5 MLG tires received flat spots, #2 tire wheel transducer and brake damage, and the brake/pressure monitoring system was compromised.
To correct the ?anti-skid fail? Issue, maintenance replaced the left anti-skid control unit in accordance with amm 32-45-01. There is no record that the anti-skid valve system 3-valve 1 replacement.
As the FAA filed it
BOEING MD-11 N294UP INCIDENT HONOLULU (HNL) 12/20/2017 0731Z [12/19/2017 2131 HST]
UNITED PARCEL SERVICE AIRLINES (UPS) EVENT REPORT 65272; CAPTAIN REPORTING;
?THIS REPORT IS ACTUALLY A REPORT OF A LEVEL 2 ANTI-SKID FAIL.
STABLE APPROACH HNL 04R. AFTER THE GEAR WAS EXTENDED AND LANDING CHECKLIST WAS COMPLETED, LEVEL
2 "ANTI-SKID FAIL" MESSAGE ILLUMINATED. F/O WAS PILOT FLYING. I READ [CAPTAIN] WHAT I THOUGHT WAS THE APPROPRIATE
CHECKLIST AND CALLED IT COMPLETE. THE TOUCHDOWN WAS NORMAL AND WHEN BRAKES WERE APPLIED AIRCRAFT
LISTED TO THE LEFT AS WE CAME TO A STOP? CAPTAIN AND FIRST OFFICER HAVE
BOTH SUBMITTED ASAP REPORTS.?
FAA INVESTIGATION:
12/20 ON APPROACH THE CREW USED ?AUTOBRAKE FAIL? CHECKLIST VERSUS THE CORRECT CHECKLIST ?ANTI-SKID FAIL?. UPS MD-11 QUICK REFERENCE HANDBOOK (QRH) PROCEDURES FOR THE ?ANTI-SKID FAIL? THE CREW SHOULD PERFORM A GO AROUND AND SETUP FOR THE LONGEST RUNWAY WITH HIGHER DEGREE OF FLAPS. CREW USED THE ?AUTOBRAKE FAIL? CHECKLIST; SELECT THE AUTO BRAKE SELECTOR TO OFF AND CONTINUE THE LANDING.
MAINTENANCE RECORD REVIEW SHOWS IN A 27-DAY PERIOD PRIOR TO THE INCIDENT, 12/20, THE ANTI-SKID SYSTEM HAD FAILED ON APPROACH 7 TIMES OUT OF 52 FLIGHTS. PRIOR 30-DAY HISTORY FROM 11/23, SHOWS NO ANTI-SKID FAIL MESSAGES.
11/23, DURING TAXI INTO ONTARIO (ONT) PILOTS RECEIVED ?R ANTI-SKID FAIL? MESSAGE. MAINTENANCE PERFORMED THE BOEING MD-11 FAULT ISOLATION MANUAL (FIM) 32-40-12-00 AND REPLACED THE ANTI-SKID CONTROL UNIT IN ACCORDANCE WITH AIRCRAFT MAINTENANCE MANUAL (AMM) 32-45-01.
LOGBOOK PAGES (L/P) # 690302-2 (11/29); L/P# 690316-2 (12/03); AND L/P# 733009-2 (12/09); ALL SHOW A LEVEL 2 ?L ANTI-SKID FAIL? ALERT APPEARED ON APPROACH AND/OR LANDING. LOGBOOK CORRECTIVE ACTIONS WERE COMPLETED WITH NO FAULTS NOTED AND ONLY LOGBOOK PAGE L/P# 690316, ITEM 2, (12/03) REFERENCED AN AMM TEST [ANTI-SKID SYSTEM TASK 32-45-00] AS BEING ACCOMPLISHED. NONE OF THE L\P?S REFERENCED SHOW THAT MAINTENANCE PERSONNEL USED THE FAULT ISOLATION MANUAL (FIM) TO TROUBLESHOOT THE ANTI-SKID SYSTEM.
12/11, UPS INITIATED AN ALERT [UPS GENERAL MAINTENANCE MANUAL (GMM) 03.27.01], MAINTENANCE ACTION ITEM PROGRAM. THE ALERT PLAN WAS DEVELOPED ON 12/12 FROM UPS MD-11 AIRCRAFT HEALTH MONITORING SYSTEM (AHMS) AND AIRCRAFT RECORDS. THE TECH RECOMMENDS WITH A DUE DATE 12/19, ?REPLACE THE A/S VALVE SYSTEM 3-VALVE 1 PER AMM 32-45-21/401. OLD STYLE VALVES HAVE AN ALIGNMENT PIN WHILE NEW STYLE DOES NOT.?
UPS MD-11 AHMS IS NOT FAA APPROVED AND/OR ACCEPTED. UPS MD-11 AHMS USES SYSTEM DATA THAT IS DOWNLOADED WHILE THE AIRCRAFT IS IN OPERATION TO ASSIST IN TROUBLESHOOTING MAINTENANCE ISSUES. THE MD-11 FIM IS A MAINTENANCE MANUAL DESIGNED TO TROUBLESHOOT FAULTS INDICATED BY THE CENTRAL FAULT DISPLAY SYSTEM (CFDS). ON THE GROUND AND IN THE COCKPIT.
L/P# 687668-2 (12/16); L/P# 687671-2 (12/16); AND L/P# 767361-2 (12/19); ALL SHOW A LEVEL 2 ?L ANTI-SKID FAIL? APPEARED ON APPROACH DURING LANDING GEAR EXTENSION. LOGBOOK CORRECTIVE ACTIONS WERE COMPLETED WITH NO FAULTS NOTED AND ONLY THE L\P DATED 12/16 AND 12/19 REFERENCE AN AMM TEST [ANTI-SKID SYSTEM TASK 32-45-00]. NONE OF THE L\P REFERENCED SHOW THAT MAINTENANCE PERSONNEL USED THE FIM TO TROUBLESHOOT THE ANTI-SKID SYSTEM.
L/P DATED: 12/20, DAY OF INCIDENT, SHOW THE FLIGHT CREW RECEIVED A LEVEL 2 ?ANTISKID FAIL? ALERT DURING GEAR EXTENSION. ON LANDING 5 MAIN LANDING GEAR (MLG) TIRES BLEW OUT, 5 MLG TIRES RECEIVED FLAT SPOTS, #2 TIRE WHEEL TRANSDUCER AND BRAKE DAMAGE, AND THE BRAKE/PRESSURE MONITORING SYSTEM WAS COMPROMISED.
TO CORRECT THE ?ANTI-SKID FAIL? ISSUE, MAINTENANCE REPLACED THE LEFT ANTI-SKID CONTROL UNIT IN ACCORDANCE WITH AMM 32-45-01. THERE IS NO RECORD THAT THE ANTI-SKID VALVE SYSTEM 3-VALVE 1 REPLACEMENT.
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