CHI01FA104

NTSB accident investigation · Airbus Industrie A320-200 · Detroit, MI · March 17, 2001

Accident · Minor injuriesField investigationFinal report
Date
March 17, 2001, 07:05 local (12:05 UTC)
Place
Detroit, MI
Injuries
3 minor, 150 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N357NWAirbus Industrie A320-200
Weather
Instrument (IMC) · Day
Status
Completed · report November 25, 2003
Report
Approved by Office Director
Parties
Airbus Industrie, NTSB, BEA, FAA, Northwest Airlines, NATCA
Safety recommendations
Yes
FAA report
20010317039169A
Case key
51932

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

On this page

Probable cause

The pilot induced oscillations and the delay in aborting the takeoff. Factors associated with the accident were the first officer used an improper trim setting and the captain did not identify and correct the setting during the taxi checklist, and the wet runway conditions.

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.

Loss of control - in flightTakeoff
Stabilator trim - improperCopilot/second pilotFactor
Stabilator trim - not correctedPilot in commandFactor
Porpoise/pilot-induced oscillation - inadvertentPilot in commandCause
Aborted takeoff - delayedPilot in commandCause
In flight collision with terrain/waterTakeoff
OverrunTakeoff - aborted
Airport facilities,runway/landing area condition - wetFactor
Terrain condition - soft
Miscellaneous/otherStanding - engine(s) not operating
Misc eqpt/furnishings,slides - disengaged
Misc eqpt/furnishings,slides - not deployed

Analysis

The Airbus A320 contacted the runway and the terrain during takeoff on runway 3C (8,500 feet by 200 feet, wet) at the Detroit Metropolitan Wayne County Airport. An emergency evacuation was made during which time the emergency evacuation slide on the 2 left (2L) door failed to deploy. The captain reported that during the initial takeoff run, he held half forward pressure until reaching 80 knots. He reported that up to this point, everything was normal. He stated he released forward stick pressure by about 100 knots and the nose of the airplane began lifting off the ground with neutral stick, which was not normal. He reported he applied about half forward stick and the nose came back down. He reported that at 120 knots the nose again began to rise with one half to one quarter stick input. He then pushed the stick forward to the forward stop and the nose came up at a rapid rate. The captain reported that his attention was focused outside the airplane and he did not hear the first officer call V1. He reported that he felt the airplane was going to stall so he pulled the power off and aborted the takeoff. The captain stated that he was trained not to perform high-speed aborted takeoffs, but he felt the airplane would have been uncontrollable if the takeoff continued. The captain stated the thrust reversers were deployed and he initially thought there was enough runway remaining to stop. He assumed the autobrakes activated, but he pressed on the brakes anyway. He reported the airplane was not decelerating and it departed the end of the runway at a high speed. The captain reported that deceleration was rapid once the airplane departed the paved surface and the engines flamed out during the ground roll. Post accident inspection of the airplane revealed the horizontal stabilizer trim was set to negative 1.7 (units of trim), when it should have been set at positive 1.7. The first officer stated he set the trim while on the taxiway. The captain did not notice the improper trim setting during the cross check which was part of the taxi checklist. Further investigation revealed the operator procedures were to set the trim using units instead of percentage of mean aerodynamic chord as recommended by the manufacturer. In addition, it was discovered that the manner in which the units of trim were displayed on the trim control wheel, on the electronic centralized aircraft monitoring system (ECAM), and in the aircraft communications addressing and reporting system (ACARS) were not consistent. As a result the Safety Board issued Safety Recommendations A-02-06 and A-02-07. Post accident examination of the 2L slide/raft that did not deploy revealed an improper chamfer on the telescopic girt bar which attaches the slide/raft to the airplane structure. This allowed the slide/raft to detach from the airplane when the 2L door was opened. As a result the Safety Board issued Safety Recommendations A-01-27 and A-01-28. Being a fly-by wire airplane, the Airbus A320 has two sources of control lag in the pitch control. One is the latency between the pilot's input and the elevator movement through the elevator aileron control (ELAC) computer and the other is the rate limit of the elevator. Examination of the digital flight data recorded data for this accident revealed the pilot changed the pitch input faster than the elevator system would respond and saturation occurred in the rate at which the elevator surface could respond to the inputs. This resulted in pilot inducted oscillations (PIO) during the takeoff roll.

Factual narrative

History of flight

On March 17, 2001, at 0705 eastern standard time, an Airbus Industrie A320-200, N357NW, operated by Northwest Airlines (NWA) as Flight 985, contacted the runway and the terrain during takeoff on runway 3C at the Detroit Metropolitan Wayne County Airport, Detroit, Michigan. The airplane received substantial damage. Three passengers reported minor injuries. The captain, co-pilot, 4 flight attendants, and 144 passengers were not injured. The 14 CFR Part 121 flight was operating in instrument meteorological conditions and an IFR flight plan was filed. The flight was originating at the time of the accident and the intended destination was Miami, Florida.

The captain stated that when he reported on the morning of the accident, he completed his paperwork then went to the airplane where he performed the captain's "flow", checked maintenance records, briefed the flight attendants, and loaded the flight plan into the multifunction control display unit (MCDU). He stated they received the load data five to six minutes before they pushed back and it was entered into the flight management guidance computer (FMGC). The V-speeds were also set while at the gate. He stated that it was snowing so he had the first officer arrange to have the airplane deiced. The captain stated the first officer set the stabilizer trim prior to reaching the deice pad.

The captain reported they taxied to the deice pad and he left the engines and auxiliary power unit (APU) running while the airplane was being deiced. Type 1 deice fluid was used, which resulted in a 15 minute hold over time, giving him 10 minutes to become airborne by time the deicing was completed. The captain reported they moved the airplane out of the deice pad before they turned the systems back on. They then completed the engines-running deicing procedure checklist and requested a taxi clearance.

The captain reported the deice pad used was only 5 or 6 airplane lengths away from the end of runway 03C. He said he performed the taxi checklist as the airplane was taxied to the end of the runway, accomplishing all the checklist items. He reported that as part of the checklist, he noted the trim setting on the electronic centralized aircraft monitoring (ECAM) display and the maximum gross load (MGL). He reported that he checked this information against the setting on the trim wheel, making sure it was in the green band. New automatic terminal information service (ATIS) information was received and he noted that the weather was deteriorating. He stated they accomplished the before takeoff checklist, and he briefed the first officer regarding what they would do in case of an engine failure on takeoff. The airplane was then cleared into position to hold, followed 30 seconds later by the takeoff clearance.

The captain reported that takeoff/go-around (TOGA) thrust was set, and he held half forward pressure on the control yoke until reaching 80 knots. He reported that up to this point, everything was normal. He stated he released forward stick pressure by about 100 knots, and the nose of the airplane began lifting off the ground with neutral stick, which was not normal. He reported he applied about half forward stick and the nose came back down. He reported that at 120 knots the nose again began to rise with one half to one quarter stick input. He then pushed the stick forward to the forward stop and the nose came up at a rapid rate. The captain reported that his attention was focused outside the airplane and he did not hear the first officer call V1. He reported that he felt the airplane was going to stall so he pulled the power off and aborted the takeoff. The captain stated that he was trained not to perform high-speed aborted takeoffs, but he felt the airplane would have been uncontrollable if the takeoff continued.

The captain stated the thrust reversers were deployed and he initially thought there was enough runway remaining to stop. He assumed the autobrakes activated, but he pressed on the brakes anyway. He reported the airplane was not decelerating and it departed the end of the runway at a high speed. The captain reported that deceleration was rapid once the airplane departed the paved surface and the engines flamed out during the ground roll.

The captain reported that he believed the tail struck the runway during the aborted takeoff, followed by the main gear and then the nose gear. He stated the impact was hard enough that he thought the airplane was structurally damaged and there was a threat of fire so he initiated an emergency evacuation of the airplane. The flightcrew performed the emergency evacuation checklist, notified the tower, and went to the back of the airplane. He reported he waited until the airplane was empty, then he exited the airplane through the 1R door and the first officer exited using the 1L door.

The first officer stated he checked in for the flight and proceeded to the gate where he met the captain and flight attendants. He received his paperwork and waited for the arriving flight to be off loaded. He then proceeded to the airplane where he checked the flight attendant log and reviewed the minimum equipment list with the captain. He then left the airplane to perform the external preflight. The first officer stated that after returning to the cockpit, he arranged to have the airplane deiced, then he continued the preflight. He reported he received the aircraft communication addressing and reporting system (ACARS) load data prior to pushback at which time he entered the request for runway 3C, and requested a pack-off variable speed takeoff. He stated he discussed this with the captain and the captain concurred. The first officer stated he entered the V speed, the zero fuel weight, and the block-out fuel weight information into the computer. He then began his "flow", accomplished the before-start checklist, and called for a pushback clearance. After pushback he called for the taxi clearance.

The first officer stated that while established on the taxiway, he set the stabilizer trim to negative 1.7 and performed the flight control check. He then received their taxi clearance to the runway 3C deice pad. The first officer stated the airplane felt normal while taxiing. The deicing checklist was then accomplished and the deicing was performed. During the deicing he reviewed the hold over chart and used "light snow" for determining the holdover time. They then accomplished the before taxi checklist and received their taxi clearance to runway 3C. The first officer stated the taxi checklist was completed, new ATIS information was received, and the before takeoff checklist was completed before the flight was cleared into position and hold. The flight was then cleared for takeoff.

The first officer stated the takeoff started off normally and he made the "80 knots thrust normal" call. He stated that at 100 knots, he felt the nose coming up and he noticed the captain was correcting for it. At about 120 knots, he felt the airplane was coming up, at which time he looked at the captain and then at the airspeed indicator. He noticed the pitch rate was unusual and the captain called "abort". He stated the airplane landed hard and proceeded off the end of the runway.

The first officer stated the captain called air traffic control (ATC). They then accomplished the emergency evacuation checklist. The captain then instructed the flight attendants to evacuate the airplane. The first officer stated he and the captain then left the cockpit and exited the airplane. He stated the emergency vehicles were already at the airplane when he exited.

Personnel information

The captain held an airline transport pilot certificate with an airplane multi-engine land rating and a commercial pilot certificate with an airplane single engine land rating. He also held an experimental aircraft builder certificate. The ca

Aircraft

Registration
N357NW
Reported as
Airbus Industrie A320-200
Category
Airplane
Serial number
830
Airframe hours
9,346
Engines
CFM International CFM56-5-A3, 26,500 lbs thrust, turbo jetCFM International CFM56-5-A3, 26,500 lbs thrust, turbo jet
Damage
Substantial damage
Flight
Part 121
Registered owner
Northwest Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 7, 2001 · 85 hours before
Departed
DTW · Detroit, MI
Destination
MIA · Miami, FL
Flight plan
IFR
Airport
DTW · Detroit Metropolitan, Wayne Co, runway 3C, 8,500 × 200 ft, asphalt

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
48
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
January 26, 2001
Seat
Left
Toxicology
Performed
Flight hours
15,600 total · 7,198 in this make and model · 155 in the last 90 days · 2 in the last 24 hours
Role
Co-pilot
Age
37
Injuries
None
Certificates
Flight engineer, Commercial, Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
April 26, 2000
Seat
Rear
Flight hours
12,500 total · 131 in the last 90 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
350° at 8 knots
Visibility
0.75 statute miles
Lowest ceiling
700 ft indefinitevv
Temperature
28 °F, dew point 27 °F
Altimeter
30.04 inHg
Observed at
DTW

Docket · 49

The files NTSB released with the investigation on June 16, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.9 MB in all.

Survival Factors 6 - Factual Report of Group ChairmanItem 1 · .PDF · 666 KBSurvival Factors 6 - Attachment 1Item 2 · .PDF · 556 KBSurvival Factors 6 - Attachment 2Item 3 · .PDF · 10.0 MBSurvival Factors 6 - Attachment 3Item 4 · .PDF · 105 KBSurvival Factors 6 - Attachment 4Item 5 · .PDF · 86 KBSurvival Factors 6 - Attachment 5Item 6 · .PDF · 72 KBSurvival Factors 6 - Attachment 6Item 7 · .PDF · 88 KBSurvival Factors 6 - Attachment 7Item 8 · .PDF · 166 KBSurvival Factors 6 - Attachment 8Item 9 · .PDF · 236 KBSurvival Factors 6 - Attachment 9Item 10 · .PDF · 112 KBSurvival Factors 6 - Attachment 10Item 11 · .PDF · 92 KBSurvival Factors 6 - Attachment 11Item 12 · .PDF · 123 KBSurvival Factors 6 - Attachment 12Item 13 · .PDF · 299 KBSurvival Factors 6 - Attachment 13Item 14 · .PDF · 380 KBSurvival Factors 6 - Attachment 14Item 15 · .PDF · 84 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 16 · .PDF · 68 KBReport on Aircraft Performance Group InvestigationItem 17 · .PDF · 1.1 MBTakeoff Trajectory StudyItem 18 · .PDF · 286 KBFlight Data Recorder - Factual Report of Group ChairmanItem 19 · .PDF · 262 KBErrata - Report on Aircraft Performance Group InvestigationItem 20 · .PDF · 11 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1 & Passenger ManifestItem 21 · .PDF · 489 KBCaptain InterviewsItem 22 · .PDF · 415 KBFirst Officer InterviewsItem 23 · .PDF · 351 KBFlight Attendant StatementsItem 24 · .PDF · 210 KBAirport DiagramItem 25 · .PDF · 51 KBWeather Information and ATISItem 26 · .PDF · 86 KBATC TranscriptsItem 27 · .PDF · 126 KBATC Personnel StatementsItem 28 · .PDF · 189 KBNTSB Safety Recommendations A-01-27 and A-01-28Item 29 · .PDF · 389 KBAirbus A320 Fuselage Station InformationItem 30 · .PDF · 49 KBFuel SlipItem 31 · .PDF · 56 KBFDR DataItem 32 · .PDF · 125 KBDTW Runway Friction Test InformationItem 33 · .PDF · 106 KBWeight and Balance InformationItem 34 · .PDF · 43 KBAirbus Checklist ItemsItem 35 · .PDF · 161 KBTrim Wheel and ECAM DisplayItem 36 · .PDF · 75 KBNorthwest Airlines ChecklistsItem 37 · .PDF · 263 KBACARS DataItem 38 · .PDF · 50 KBNTSB Safety Recommendations A-02-06 and A-02-07Item 39 · .PDF · 215 KBStatement of Party Representatives to NTSB InvestigationItem 40 · .PDF · 338 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 41 · .PDF · 43 KBPhoto 1. Impact Marks on Runway 03CItem 42 · .PDF · 201 KBPhoto 2. Area Where N357NW Exited the RunwayItem 43 · .PDF · 184 KBPhoto 3. Aft Fuselage Damage to N357NWItem 44 · .PDF · 162 KBPhoto 4. Aft Fuselage Damage to N357NWItem 45 · .PDF · 180 KBPhoto 5. Internal Damage to the Aft Fuselage of N357NWItem 46 · .PDF · 168 KBPhoto 6. Trim Setting as Found After the AccidentItem 47 · .PDF · 204 KBPhoto 7. Stabilator Trim PositionItem 48 · .PDF · 110 KBPhoto 8. N357NW Off the End of Runway 03CItem 49 · .PDF · 43 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.