20171219023319I

Incident · Minor damage

FAA incident report · Boeing MD-11F · Honolulu, HI · December 19, 2017

Date
December 19, 2017 · 21:31 local
Place
Honolulu, HI
Airport
Honolulu International
Phase of flight
Landing: Touchdown
Operating rules
Air carrier (Part 121)
Operator
IPXA
Damage
Minor damage
Aircraft
N294UP
Reported as
Boeing MD-11F
Reported engine
Pratt & Whitney PW4460
People aboard
2
Fatal injuries
0
Other injuries
0
Pilot’s certificate
Airline transport
Pilot’s flight hours
6,476 total4,835 in this make and model155 in the last 90 days

From the FAA’s Accident/Incident Data System (AIDS), through its Aviation Safety Information Portal, as reported. The NTSB investigates accidents separately, and its record of an accident is the fuller one. The aircraft is matched to the registry by N-number and event date, checked against the reported make and model; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

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.

Other reports on N294UP · 1

Matched to the same aircraft by N-number and date.