CHI08IA065

NTSB incident investigation · Boeing 737-2H4 · Lincoln, NE · January 8, 2008

Incident · No injuriesIncident investigationFinal report
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.

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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.

Hydraulic power systemAircraft › Aircraft systems · FailureBoeing 737-2H4: 1 caseAll aircraft: 22 casesProbable cause
Terrain: wet/muddy terrainEnvironmental issues › Physical environment · Not specifiedBoeing 737-2H4: 1 caseAll aircraft: 110 cases
Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelBoeing 737-2H4: 1 caseAll aircraft: 1,386 casesProbable cause
Terrain: snowy/icy terrainEnvironmental issues › Physical environment · Not specifiedBoeing 737-2H4: 1 caseAll aircraft: 77 cases

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.