- Date
- January 8, 2008, 17:45 local (23:45 UTC)
- Place
- Lincoln, NE
- Injuries
- 38 uninjured
- Damage
- No damage
- Phase of flight
- Taxi
- Aircraft
- N733TWBoeing 737-2H4
- Defining event
- Taxi-from runway: Sys/Comp malf/fail (non-power)
- Weather
- Visual (VMC) · Night
- Status
- Completed · report July 30, 2008
- Report
- Approved by Office Director
- Parties
- Federal Aviation Administration
- FAA report
- 20080108000219I
- Case key
- 67416
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 improper installation of the swivel valve fittings by the operator's mechanic leading to the total loss of both hydraulic systems. Contributing to the incident were the swivel valves leaking and the total failure of the hydraulic system.
Findings · 4
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
Two days before the incident flight, the airplane was placed in maintenance for a "[Left/Hand Main Landing Gear] swivel valve leaking." The corrective action was accomplished by one of the operator's mechanics. The mechanic reportedly removed both the swivel valves on the left main landing gear. The aft swivel valve was removed and replaced with a new valve. The forward valve was removed and reinstalled. That valve was checked for leaks and the airplane was returned to service prior to the incident flight. The airplane, on a non-scheduled domestic passenger flight, was taxiing after landing, exited the taxiway, and became stuck in snow and mud despite the pilot's attempts to maintain directional control. The captain reported a total loss of all hydraulic systems. The airplane's maintenance manual 32-41-61 contained a warning that stated, "WARNING: MAKE SURE THAT THE SWIVEL JOINT AND HYDRAULIC LINES ARE ORIENTED AS SHOWN ... . THE HYDRAULIC LINE TO THE BRAKE ASSEMBLY MUST BE CONNECTED TO THE SWIVEL HOUSING AND THE HYDRAULIC LINE FROM THE ANTI-SKID VALVE TO THE SWIVEL FITTING AS SHOWN ... . IF THE ASSEMBLY OF THE SWIVEL AND THE HYDRAULIC LINES ARE ROTATED 180 DEGREES, THE HYDRAULIC LINES CAN BE CONNECTED BUT THE SWIVEL WILL NOT OPERATE. THIS CAN CAUSE THE HYDRAULIC LINES TO BREAK DURING EXTENSION AND RETRACTION AND CAUSE THE BRAKES PRESSURE TO BE LOST." Examination of the swivel valves after the incident revealed that both valves were not installed as depicted in the maintenance manual.
Factual narrative
On January 8, 2008, about 1745 central standard time, N733TW, a Boeing 737-2H4, operated by Ameristar Air Cargo, Inc., sustained no damage when it lost directional control and exited the taxiway while taxiing from landing at the Lincoln Airport (LNK), near Lincoln, Nebraska. The non-scheduled domestic passenger flight was operating under 14 CFR Part 121. The airline transport rated pilot and co-pilot, 4 flight attendants, 1 jump seat occupant, and 31 passengers were uninjured after deplaning via the airplane's airstairs. Visual meteorological conditions prevailed at the time of the accident. The flight originated about 1559 from the Austin-Bergstrom International Airport, near Austin, Texas, and was destined for LNK.
The operator reported that on January 6, 2008, the airplane was in maintenance for a "[Left/Hand Main Landing Gear] swivel valve leaking." The corrective action was accomplished by one of the operator's mechanics. The mechanic reportedly removed both the swivel valves on the left main landing gear. The aft swivel valve was removed and replaced with a new valve. The forward one was removed and reinstalled. That maintenance was checked for leaks and the airplane was returned to service.
The airplane's maintenance manual 32-41-61 contained a warning that stated:
Warning: make sure that the swivel joint and
Hydraulic lines are oriented as shown ... . The
Hydraulic line to the brake assembly must be
Connected to the swivel housing and the
Hydraulic line from the anti-skid valve to the
Swivel fitting as shown ... . If the assembly of
The swivel and the hydraulic lines are rotated
180 Degrees, the hydraulic lines can be
Connected but the swivel will not operate. This
Can cause the hydraulic lines to break during
Extension and retraction and cause the brakes
Pressure to be lost.
The captain, in part, stated:
At about 12 miles from the airport with runway 36 insight and the
airspeed at 210 knots started extending the flaps on schedule. When
lowering the gear we performed the Before Landing Checklist and
observed all systems normal upon completing the checklist and the
flaps at 30 degrees. I landed on runway 36 in Lincoln, NE (LNK)
with all systems normal and exited taxiway Juliet to the right per
tower instructions. As I exited runway 36 I then stowed the speed
brakes and called for the after landing checklist. ...
While taxiing to parking ... the Master Caution "HYD" Light
illuminated followed by an immediate loss of System "B" Hydraulics.
I immediately started trying to get the airplane stopped and observed
no braking and no response to tiller movement for nose wheel
steering. I then tried to deploy the thrust reversers and couldn't get
the [thrust reverser]'s to deploy. Within a few seconds after the loss
of System B, we observed that a total loss of System "A" Hydraulics
had occurred as well.
In this very short time period the airplane started a slight turn to the
left. I was applying the right rudder with no response in the steering.
I then asked for assistance from [the] First Officer ... with the right
rudder. The [a]irplane exited the taxiway to the left into the mud and
snow.
After coordinating with fire and rescue, I made the decision to use
the aircraft stairs to deplane the passengers.
Examination of the swivel valves after the incident revealed that both valves were not installed as depicted in the maintenance manual.
Aircraft
- Registration
- N733TW
- Reported as
- Boeing 737-2H4
- Category
- Airplane
- Serial number
- 22732
- Airframe hours
- 71,959
- Engines
- Pratt & Whitney JT8D-17, turbo fanPratt & Whitney JT8D-17, turbo fan
- Damage
- No damage
- Flight
- Part 121
- Operator
- Ameristar Air Cargo, Inc.
- Registered owner
- Sierra American Corp
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · November 1, 2007
- Departed
- AUS · Austin, TX
- Destination
- Lincoln, NE
- Flight plan
- IFR
- Airport
- LNK · Lincoln Muni, runway 36, 12,901 × 200 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
- Injuries
- None
- Certificates
- Flight engineer, Commercial, Airline transport
- Airplane ratings
- Multi-engine land, Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Unknown
- Seat
- Left
- Flight hours
- 15,000 as pilot in command
- Role
- Co-pilot
- Injuries
- None
- Certificate
- Airline transport
- Airplane ratings
- Multi-engine land
- Medical
- Class 1, Unknown
- Seat
- Right
- Flight hours
- 3,380 in this make and model · 15,000 as pilot in command
Weather
- Conditions
- Visual (VMC) · Night
- Wind
- 280° at 6 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 37 °F, dew point 23 °F
- Altimeter
- 30.05 inHg
- Observed at
- LNK
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.