CHI08LA071

NTSB accident investigation · Airbus Industrie A319-114 · Detroit, MI · January 9, 2008

Accident · No injuriesLimited investigationFinal report
Date
January 9, 2008, 07:49 local (12:49 UTC)
Place
Detroit, MI
Injuries
73 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N349NBAirbus Industrie A319-114
Defining event
Approach: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 2008
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20080109844059A
Case key
67425

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 separation of the engine cowling which resulted from maintenance personnel failing to follow maintenance procedures in that they did not latch the engine cowling following the maintenance inspection. A factor associated with the accident was their attention was divereted from the task when another mechanic asked for assistance.

Findings · 3

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.

Attention/monitoring: attentionPersonnel issues › Psychological · Maintenance personnelAirbus A319-114: 1 caseAll aircraft: 226 casesProbable cause
Power plant: engine cowling systemAircraft › Aircraft power plant · FailureAirbus A319-114: 1 caseAll aircraft: 11 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Maintenance personnelAirbus A319-114: 1 caseAll aircraft: 440 casesProbable cause

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

The accident flight was the first one for the airplane after having maintenance performed on the number two (right) engine during the previous evening. The first officer reported the engine cowls were flush and he did not see any "hanging" cowl latches when he looked underneath the engine cowls during the preflight. The captain reported the preflight, taxi, and takeoff were normal. During climb out the lead flight attendant informed the pilots that a passenger reported that the number two engine cowling was flapping after takeoff. The captain then began to monitor the N1 vibration indications on the number two engine. He reported that the vibration was approximately double the indication from the number one engine, but the indicator was not flashing, nor had it turned amber. The captain reported that during cruise flight the number two engine vibration decreased and about 20 minutes after they leveled off, the airplane shuddered. He reported the remainder of the flight was normal until they were taxiing after landing and the lead flight attendant called the cockpit stating that "part of the right engine had come off." Half of the engine cowl departed the airplane when it was on a one mile final. The other half departed the airplane as it touched down. Another airplane subsequently contacted this part of the cowling when it landed after the accident airplane. Contract maintenance personnel reported they changed the N1 sensor on the number two engine. They reported they shut the fan cowling, but did not latch it as they still needed to perform an engine run and check for leaks. They performed the engine run and were in the cockpit when another mechanic asked for help on another airplane. The mechanics left the accident airplane to assist the other mechanic. Neither mechanic returned to the accident airplane to either latch or verify that the fan cowling had been latched. The aircraft maintenance manual (AMM) instructions for replacing the N1 sensor states, "Close the fan cowl doors (Ref. AMM TASK 71-13-00-410-040)." This task was not completed prior to the airplane being returned to service. The separated cowling contacted the right side of the horizontal stabilizer which resulted in substantial damage to the stabilizer. In addition, the fan cowl doors, number two engine pylon, the number two engine reverser, and the right wing number one slat were damaged.

Factual narrative

On January 9, 2008, at 0749 eastern standard time, an Airbus Industrie A319-114, N349NB, operated by Northwest Airlines as flight 853, experienced an engine fan cowling separation while on approach to land on runway 27R at the Detroit Metro Airport (DTW), Detroit, Michigan. The pilot, co-pilot, 3 flight attendants, and 68 passengers on board were not injured. The airplane received substantial damage. The domestic passenger flight was being operated under 14 Code of Federal Regulations Part 121. The flight was operating in visual meteorological conditions and an instrument flight plan was filed. The flight originated from LaGuardia Airport (LGA), New York, New York, at 0618.

The accident flight was the first one for the airplane after having maintenance performed on the number two (right) engine during the previous evening. The first officer reported he used a flashlight when conducting his preflight inspection of the airplane as it was still dark outside. He reported the engine cowlings were flush, and he did not see any "hanging" cowl latches when he looked underneath the engines.

The captain reported that the logbooks indicated the number two engine vibration monitor had been replaced during the previous night. He reported the preflight, taxi, and takeoff were normal. The captain reported that during climb out the cockpit received a call from the lead flight attendant who informed them that a passenger reported that the number two engine cowling was flapping after takeoff. A pilot-passenger who was sitting behind this passenger reportedly did not see the cowling move, nor did the flight attendants when they looked out the window. The captain reported he then began to monitor the N1 vibration indications on the number two engine. He reported that the number two engine vibration was approximately double the indication from the number one engine, but the indicator was not flashing nor had it turned amber. During cruise flight the number two engine vibration decreased to equal that of the number one engine. The captain reported that about 20 minutes after they leveled off, the airplane shuddered as if flying through wake turbulence. The captain reported he then reviewed the logbooks and noticed previous write-ups regarding engine vibration, so he sent an AIRINC Communications Addressing and reporting System (ACARS) maintenance message regarding the current vibration. He reported the remainder of the flight was normal until they were taxiing after landing and the lead flight attendant called the cockpit stating that "part of the right engine had come off." The first officer called ground control to warn them that there might be debris on the runway. The crew then shut down the number two engine and taxied to the gate.

The pilot of another airplane later reported seeing part of the engine cowling come off when flight 853 was on a 1-mile final. The other half of the engine cowling was found on the runway and was contacted by an airplane that landed after the accident airplane.

Contract maintenance personnel reported they changed the N1 sensor on the number two engine during the evening prior to the accident. They reported they then shut the fan cowling, but did not latch it as they still needed to perform an engine run and check for leaks. After the engine run was performed, one of the mechanics thought that the other had latched the fan cowling when in fact he had not. While they were doing another task in the cockpit, another mechanic asked for help at another gate. The mechanics left the accident airplane to assist the other mechanic. Neither mechanic returned to the accident airplane to either latch or verify that the fan cowling had been latched.

The maintenance log stated the N1 speed sensor was removed and replaced in accordance with aircraft maintenance manual (AMM) 77-11-10. This section of the AMM states, "Close the fan cowl doors (Ref. AMM TASK 71-13-00-410-040)." According to the maintenance personnel, this task was not completed prior to the airplane being returned to service.

The separated cowling contacted the right side of the horizontal stabilizer which resulted in substantial damage to the stabilizer. In addition, the fan cowl doors, number two engine pylon, the number two engine reverser, and the right wing number one slat were damaged.

Aircraft

Registration
N349NB
Reported as
Airbus Industrie A319-114
Category
Airplane
Serial number
1815
Airframe hours
15,029
Engine
CFM International CFM56-5-A5, 23,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Northwest Airlines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 1, 2007 · 317 hours before
Departed
LGA · New York, NY
Destination
DTW · Detroit, MI
Flight plan
IFR
Airport
DTW · Detroit Metro, runway 27R, 8,700 × 200 ft

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
52
Injuries
None
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 1, 2006
Seat
Left
Flight hours
13,615 total · 8,079 in this make and model · 6,797 as pilot in command · 281 in the last 90 days · 88 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
46
Injuries
None
Certificates
Airline transport, Flight engineer, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 1, 2007
Seat
Rear
Flight hours
7,161 total · 4,103 in this make and model · 232 in the last 90 days · 66 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 15 knots
Visibility
10 statute miles
Lowest ceiling
3,800 ft broken
Temperature
39 °F, dew point 30 °F
Altimeter
29.89 inHg
Observed at
DTW, 1 nm away

Docket · 15

The files NTSB released with the investigation on May 12, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.8 MB in all.

FAA reports on this event · 1

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