ATL07IA078

NTSB incident investigation · Airbus Industrie A319-111 · Atlanta, GA · April 22, 2007

Incident · No injuriesIncident investigationFinal report
Date
April 22, 2007, 06:24 local (10:24 UTC)
Place
Atlanta, GA
Injuries
129 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N904FRAirbus Industrie A319-111
Weather
Visual (VMC) · Day
Status
Completed · report June 27, 2007
Report
Approved by Office Director
Parties
College Park FSDO-11
Case key
65613

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The mechanics failure to follow procedures and directives in securing the lower engine cowling after maintenance, and the failure of the first officer to follow the checklist to ensure the engine cowling was secured during the walk around inspection resulting in the separation of the right lower engine cowling during initial take off climb.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherClimb
Cooling system,cowling - not secured
Procedures/directives - not followedCompany maintenance personnelCause
Checklist - not followedCopilot/second pilotCause
Cooling system,cowling - separation

Analysis

The lower right engine cowling separated during the takeoff intitial climb. The pilot-in command (PIC) stated the flight deck crew arrived at the airplane at the required show time. The gate agent informed the flight deck crew that a mechanic was working on the brakes. The PIC and first officer (FO) went down to the airplane, did not see anyone, and the logbook was not on the flight deck. The FO departed the flight deck, completed the walk around inspection, and observed nothing unusual. A short time later the mechanic brought the logbook to the flight deck and explained to the PIC that he had worked on the No.1 brake and placed the temperature sensor on the minimum equipment list. The lower right engine cowling separated on initial climbout at 200 feet resulting in a loss of the yellow hydraulic pressure system. The flight crew leveled the airplane off at 3,000 feet, declared an emergency, the flight was cleared by the air traffic controller for an approach to runway 9 left, and landed without further incident. Examination of the airplane's right engine lower cowling by an FAA inspector after the incident revealed all three latches were in the unlocked position. The latch fitting on the aft position was missing and the bolt that secures it was broken. The two forward fittings were in good condition and showed no signs of stress. " The A319 STANDARD OPERATING PROCEDURES EXTERIOR INSPECTION states in GENERAL, "The exterior inspection ensures that the overall condition of the aircraft and its visible components and equipment are safe for the flight. Complete inspection is normally performed by maintenance personnel or in the absence of maintenance personnel by a flight crewmember before each originating flight. Items marked by asterisks (*) must be performed by a flight crewmember before each flight." Item 7, ENG 2 LH SIDE, and item 19, ENG 2 RH SIDE both have an asterisk next to Fan cowl doors, CLOSED/LATCHED." Review of FRONTIER AIRCRAFT FLIGHT LOG for Aircraft Number 904 revealed the Integrated Drive Generator (IDG) required servicing on April 22, 2007. The mechanic endorsed the FRONTIER AIRCRAFT MAINTENANCE NON-ROUTINE SUPPLEMENT SHEET on April 22, 2007, "Serviced #2 IDG IAW AMM 24-21-00-03-02." The FRONTIER MAINTENANCE LINE CHECK LIST, HEAVY SERVICE, CARD No. HS 2010-1, dated February 26, 2007 states on page 7 item 15.1, "Cowlings: panels, air outlets, security of latches." The mechanic indicated with his initials and social security number that this task had been complied with on April 22, 2007. The mechanic entered his initials and social security number on page 12 item 20.1 stating, "Endorse corrective actions in technical log book and sign against each corrected or carried forward item."

Factual narrative

On April 22, 2007, at 0624 eastern daylight time, an Airbus A319-111, N904FR, Frontier Flight 851, operating as a 14 CFR Part 121 scheduled domestic passenger flight, registered to RBS Aerospace Limited, operated by Frontier Airlines, Inc, experienced a loss of the right lower engine cowling on initial climb out at 200 feet, and the loss of the yellow hydraulic pressure system. The flight crew leveled the airplane off at 3,000 feet and declared an emergency. The flight was cleared for an approach to runway 9 left and landed with out further incident at the William B. Hartsfield Atlanta International Airport, Atlanta, Georgia at 0642. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane received minor damaged. The airline transport rated pilot-in-command (PIC), first officer (FO), three flight attendants, and one hundred twenty four passengers reported no injuries. The flight was originating from the William B. Hartsfield International Airport, Atlanta, Georgia, on April 22, 2007; at 0624.The planned destination airport was Denver International Airport, Denver, Colorado.

The PIC stated the flight deck crew arrived at the airplane at the required show time. The gate agent informed them that a mechanic was working on the brakes. The PIC and FO went down to the airplane and did not see anyone and the logbook was not on the flight deck. The FO departed the flight deck, completed the walk around inspection, and observed nothing unusual. A short time later the mechanic brought the logbook to the flight deck and explained to the PIC that he had worked on the No.1 brake and placed the temperature sensor on the minimum equipment list.

Examination of the airplane right engine lower engine cowling by an FAA inspector after the incident revealed all three latches were in the unlocked position. The latch fitting on the aft position was missing and the bolt that secures it was broken. The two forward fittings were in good condition and showed no signs of stress.

Review of Frontier Flight Operations Manual-Volume II, Exterior Inspection, General, states, "The exterior inspection is normally performed by the first officer unless briefed otherwise by the captain. This check ensures that the overall condition of the aircraft and its visible components and equipment are safe for flight. A complete exterior inspection must be performed by a flight crewmember before each originating flight." The Exterior Walk Around Inspection states in item 7, "ENG LH SIDE....-* Fan cowl doors, CLOSED/LATCHED. The checklist further states in item 19, "ENG RH SIDE....-*Fan cowl doors, CLOSED/LATCHED." The A319 STANDARD OPERATING PROCEDURES EXTERIOR INSPECTION states in GENERAL, "The exterior inspection ensures that the overall condition of the aircraft and its visible components and equipment are safe for the flight. Complete inspection is normally performed by maintenance personnel or in the absence of maintenance personnel by a flight crewmember before each originating flight. Items marked by asterisks (*) must be performed by a flight crewmember before each flight." Item 7, ENG 2 LH SIDE, and item 19, ENG 2 RH SIDE both have an asterisk next to Fan cowl doors, CLOSED/LATCHED."

Review of FRONTIER AIRCRAFT FLIGHT LOG for Aircraft Number 904 revealed the Integrated Drive Generator (IDG) required servicing on April 22, 2007. The mechanic signed off on the FRONTIER AIRCRAFT MAINTENANCE NON-ROUTINE SUPPLEMENT SHEET on April 22, 2007, "Serviced #2 IDG IAW AMM 24-21-00-03-02." The FRONTIER MAINTENANCE LINE CHECK LIST, HEAVY SERVICE, CARD No. HS 2010-1, dated February 26, 2007 states on page 7 item 15.1, "Cowlings: panels, air outlets, security of latches." The mechanic indicated with his initials and social security number that this task had been complied with on April 22, 2007. The mechanic entered his initials and social security number on page 12 item 20.1 stating, "Endorse corrective actions in technical log book and sign against each corrected or carried forward item."

Review of the airplane log books revealed the airplane was equipped with the modifications outlined in AD2003-18-6 and amendment 39-13297, which mandates the installation of a hold open device for the cowl doors as well as a modification of the latch handles to ensure that the unfastened latch handle will hang down.

Airbus previously issued a Operator's Telex to "A319/A320?A421 V2500 operators." The telex recommended that, in addition to mandatory compliance wit AD 2003-18-06, operator's consider the following:"… strictly adhere to AMM Task 71-13-00 for proper latching and closing of fan cowl doors after each maintenance action requiring cowl opening…. It is essential that a flight crew member visually inspects the fan cowl doors prior to each flight to ensure that they are closed and latched."

The pilot-in-command, first officer, and mechanic were tested for ethanol, basic, acidic, and neutral drugs. All results were normal.

Aircraft

Registration
N904FR
Reported as
Airbus Industrie A319-111
Category
Airplane
Serial number
1579
Airframe hours
19,419
Engine
General Electric CFM56-5B85P, 22,000 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Frontier Airlines, Inc
Registered owner
RBS Aerospace Limited
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 1, 2007
Departed
KATL · Atlanta, GA
Destination
KDEN · Denver, CO
Flight plan
IFR
Airport
KATL · William B. Hartsfield Int, runway 09L, 11,889 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
12,750 total · 2,400 in this make and model · 11,650 as pilot in command · 240 in the last 90 days · 80 in the last 30 days · 6 in the last 24 hours
Role
Co-pilot
Age
36
Injuries
None
Certificates
Flight instructor, Commercial, Airline transport
Last flight review
April 1, 2007
Seat
Right
Flight hours
7,469 total · 2,450 in this make and model · 2,256 as pilot in command · 157 in the last 90 days · 95 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 45 °F
Altimeter
30.20 inHg
Observed at
KATL

Docket · 15

The files NTSB released with the investigation on May 22, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.3 MB in all.