DCA05MA095

NTSB accident investigation · Boeing 747-200 · Agana · August 19, 2005

Accident · Minor injuriesMajor investigationFinal report
Date
August 19, 2005, 14:18 local (04:18 UTC)
Place
Agana
Injuries
2 minor, 338 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N627USBoeing 747-200
Weather
Visual (VMC) · Day
Status
Completed · report December 30, 2008
Report
Approved by Office Director
NTSB office
Major Investigations Division
Parties
AMFA, ALPA - NWA, FAA, Boeing, NWA
FAA report
20050819020349A
Case key
62281

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 flight crews' failure to verify that the number of landing gear annunciations on the second officer’s panel was consistent with the number specified in the abnormal/emergency procedures checklist, which led to a landing with the nose gear retracted.

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.

Wheels up landingLanding
Landing gear,gear indicating system - activated
Checklist - not followedFlightcrewCause
Gear extension - not verifiedFlightcrewCause
Landing gear,nose gear

Analysis

During the initial approach, the red GEAR annunciator light above the gear lever illuminated, and the landing gear warning horn sounded after the gear handle was selected down and the flaps were selected to 25 degrees. During the go-around, the captain asked the second officer (SO), "what do you have for the gear lights?" The SO responded, "four here." When all gear are down and locked on the Boeing 747-200, the landing gear indication module located on the SO’s instrument panel has five green lights: one nose gear light above four main landing gear lights. The crew then read through the "Red Gear Light Remains On (After Gear Extension)" emergency/abnormal procedure from the cockpit operations manual to troubleshoot the problem. Although the checklist twice presented in boldface type that five lights must be present for the gear to be considered down and locked, the crew did not verbalize the phrase either time. The captain did not directly request a count, and the SO did not verbally confirm, the number of gear down annunciator lights that were illuminated; instead, the flight crew made only general comments regarding the gear, such as "all gear," "all green," or "got 'em all." Because the crew believed that all of the gear annunciator lights were illuminated, they considered all gear down and locked and decided not to recycle the landing gear or attempt to extend any of the gear via the alternate systems before attempting a second approach. During all communications with air traffic control, the flight crew did not specify the nature of the problem that they were troubleshooting. Although the checklist did not authorize a low flyby, if the flight crewmembers had verbalized that they had a gear warning, the controller most likely would have been able to notify the crew of the nose gear position before the point at which a go-around was no longer safe. Multiple gear cycles were conducted after the accident, and the nose gear extended each time with all nose gear door and downlock indications correctly displayed on the landing gear indication module. Postaccident examination of the nose gear door actuator found that one of the two lock keys was installed 180 degrees backward. Although this improper configuration could prevent proper extension of the nose gear, the actuator had been installed on the accident airplane since 2001 after the actuator was overhauled by the operator. No anomalies were found with the landing gear indication module, the nose gear-operated door sequence valve, and the nose/body landing gear selector valve.

Factual narrative

History of flight

On August 19, 2005, about 1419 local time, Northwest Airlines (NWA) flight 74, a Boeing 747-200, N627US, landed on runway 06L with its nose gear retracted at Guam-Antonio B. Won Pat International Airport (GUM) Agana, Guam. An emergency evacuation was initiated several minutes after the airplane came to a stop on the runway. Of the 16 crewmembers and 318 passengers onboard, 2 received minor injuries during the evacuation. The airplane was substantially damaged. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and was en route from Tokyo-Narita International Airport, Narita, Japan. Visual meteorological conditions prevailed at the time of the accident.

The captain was the flying pilot. According to crewmember statements, the takeoff, climb, en route, descent, and initial approach phases of the flight were normal. According to the cockpit voice recorder (CVR), about 1403:28, the local controller (LC) cleared flight 74 for the visual approach to runway 6L and subsequently cleared the flight to land.

About 1405:56, the captain called for "gear down, flaps 20" and the first officer (FO) immediately responded "gear down." About 1406:36, the captain requested, "flaps 25, the landing check." Three seconds later, a sound similar to the landing gear warning horn started. The FO stated, "oh sorry," a crewmember stated, "we didn’t get a gear," and then the captain requested, "put it back to 20." About 1406:47, the second officer (SO) stated "red gear light," and the landing gear warning horn sound stopped.

About 1406:54, the captain stated, "uh, tell 'em we’re gonna have to go around. Hold out to the left here. Flaps ten." About 1407:02, the FO called the LC and advised, "tower, Northwest 74, we’re gonna uh, do a go-around. We’d like to hold out to the west while we work on a problem." The LC then cleared the flight to fly the runway heading and climb and maintain 2,600 feet.

About 1407:27, the captain asked the SO, "what do you have for the gear lights?" The SO responded, "four here." The LC then advised the flight crewmembers to contact Guam departure.

About 1407:57, the controller asked, "your intentions?" to which the FO responded, "uh, we’d just like to uh, go someplace sir we can delay for a few minutes while we work on some light problems." The flight was then cleared to remain VFR.

About 1409:01, the captain instructed the FO, "okay you’re gonna take the airplane here. I’m gonna work with him." The SO and the captain then started to complete the "Red Gear Light Remains On (After Gear Extension)" emergency/abnormal procedure in the cockpit operations manual. The SO began reading, "the landing gear lever is seated in the down detent," and the captain responded, "it is." Next, the SO stated, "okay press the landing gear annunciator gear primary switch," and the captain asked, "okay, you got all the gear … green down, right?" to which the SO responded, "all gear" and then "yeah. Right there. Okay, if uh, gear down not illuminated."

About 1410:02, the SO read out loud the note in the procedure that stated that the gear could be recycled depending on the flight crew’s assessment. The captain asked, "I think we’d cycle it one time, don’t you?" The SO responded, "yeah," and the captain continued, "you see any reason not to cycle it?" The SO further responded, "no, I don’t," and then the FO asked "what gear are down and what are up?" Both the captain and SO responded, "all of 'em are down."

The captain continued, "you’re getting green lights in primary. Hit alternate. You get green lights in alternate, all of 'em left … on the gear." About 1410:41, the FO asked, "so tell me what the red light’s for? Are your gear doors okay?" After a short discussion, the SO stated, "it’s all good? It looks good back here."

About 1410:52, the FO stated "this is just technique. This is not airplane, but if I got good gear, I won’t put 'em back up…. If I could determine, you know, why I’ve got a red light but is I’ve got gears down and green, I probably would take it that way," to which the captain responded, "okay." The SO read, "carrot here says if gear down annunciator light for any gear illuminates in either primary or alternate, that gear can be considered down and locked."

About 1411:26, the captain asked, "so it is down and locked?" to which the SO responded, "down and locked." The three flight crew continued to discuss the situation and then, according to postaccident crew statements, the SO handed the procedure to the captain.

About 1412:20, the captain read, "flybys are considered to be of no value. Okay, insure the landing gear lever is seated down, in the down detent. It is seated. All right, press the landing gear annunciator green primary. It’s all green." He then continued reading the last statement in the procedure, "if gear down annunciator light for any one of the five gear is not illuminated, press the alternate. Well we got 'em all. You don’t have to do that." The SO states, "we got 'em all. We don’t have to do that." The captain reread the last statement and concluded, "we’re down and locked," and the SO responded, "good to go."

About 1413:19, the captain called the controller and stated that the flight crewmembers had "sorted out the problem" and "we’re ready to return for runway 6L." The flight was then cleared for a visual approach.

While on the visual approach, the captain stated, about 1414:54, "you’re gonna have to pull the gear, the horn uh, indicator," and "you see any reason to declare or anything other than just normal here?" The SO responded, "not yet," and the captain agreed. The FO then stated, "you know we still don’t know why it’s that way, though, right?" and the captain responded, "no."

The FO continued, "okay, but we ran through it and it said gear’s down and everybody’s happy." The captain responded, "yeah, now if you want to read the thing, read it. We’ve got plenty of time. We’ve got 37 thousand pounds of gas. We’re indicating green on both primary and alternate on the gear."

About 1415:27, the FO radioed the LC, and the flight was subsequently cleared to land on runway 6L. As the flight continued the approach, the captain asked, about 1416:07, "did you find that horn?" and the SO responded, "yep." The captain then stated, "okay, you can pull it." The flight crew continued the approach and completed all of the before landing checklist items.

About 1418:17, the CVR recorded a sound similar to touchdown, and, about 1418:22, the SO stated, "reversers normal." Three seconds later, the LC radioed "Northwest 74, go around. Uh, negative, uh, nosewheel." About 1418:26, the CVR recorded a sound similar to increasing engine RPM and the SO stating, "seventy percent," and then the FO and SO both stated "go around" multiple times. About 1418:37 the LC queried "Northwest 74, tower," but the FO radioed "we’re unable."

About 1418:51, the CVR recorded the sound of impact, and then the captain stated "standby with the evacuation checklist." The FO then radioed the LC, asking if he could see any fire, and the LC responded, "negative." About 1419:56, the captain informed the passengers via the public address system that the nose gear had collapsed and that they were to remain seated. The CVR stopped recording about 1420:35.

According to postaccident interviews, a flight attendant notified the captain of smoke in the forward cabin area. The captain advised the FO and SO to secure the cockpit, and he went downstairs to assess the situation. The captain stated that he "saw smoke coming from an access hatch and told the flight attendants to move the passengers aft of door two." He also directed the upper deck flight attendant to move the passengers from the upper deck down to the main cabin deck and aft of door two. When he noticed that

Aircraft

Registration
N627US
Reported as
Boeing 747-200
Category
Airplane
Serial number
21709
Airframe hours
95,270
Engines
Pratt & Whitney JT9D-7Q, 53,000 lbs thrust, turbo fanPratt & Whitney JT9D-7Q, 53,000 lbs thrust, turbo fanPratt & Whitney JT9D-7Q, 53,000 lbs thrust, turbo fanPratt & Whitney JT9D-7Q, 53,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Northwest Airlines Inc
Airworthiness certificate
Standard, Transport; Standard, Normal
Departed
RJAA · Tokyo
Destination
PGUM · Agana
Flight plan
IFR
Airport
GUM · Guam-Antonio B. Won Pat, runway 06L, 10,015 × 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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 20, 2004
Seat
Left
Flight hours
7,850 total · 7,850 in this make and model · 2,350 as pilot in command · 184 in the last 90 days · 86 in the last 30 days · 12 in the last 24 hours
Role
Co-pilot
Age
46
Injuries
None
Certificates
Commercial, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 23, 2005
Seat
Right
Flight hours
9,100 total · 8,695 in this make and model · 208 in the last 90 days · 75 in the last 30 days · 12 in the last 24 hours
Role
Flight engineer
Age
61
Injuries
None
Certificates
Flight engineer, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Rear
Flight hours
8,720 total · 345 in this make and model · 4,110 as pilot in command · 163 in the last 90 days · 100 in the last 30 days · 9 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 4 knots
Visibility
10 statute miles
Lowest ceiling
2,500 ft broken
Temperature
84 °F, dew point 77 °F
Altimeter
29.82 inHg

Docket · 30

The files NTSB released with the investigation on May 2, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.1 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 148 KBOperations 2 - List Of AttachmentsItem 2 · .PDF · 80 KBOperations 2 - A1 Flight Crew StatementsItem 3 · .PDF · 1.0 MBOperations 2 - A2 Landing Gear Systen DescriptionItem 4 · .PDF · 353 KBOperations 2 - A3 Landing Gear Ops And IndicationsItem 5 · .PDF · 785 KBOperations 2 - A4 Alternate Landing Gear OperationItem 6 · .PDF · 402 KBOperations 2 - A5 Manual Nose Gear ExtensionItem 7 · .PDF · 441 KBOperations 2 - A6 Procedures Red Light ON After Gear ExtensionItem 8 · .PDF · 198 KBOperations 2 - A7 Boeing Ops Manual BulletinItem 9 · .PDF · 443 KBOperations 2 - A8 Previous Flight Crew StatementsItem 10 · .PDF · 675 KBOperations 2 - A9 NTSB Operator Accident ReportItem 11 · .PDF · 140 KBOperations 2 - A10 Boeing Ops Manual ExcerptItem 12 · .PDF · 152 KBOperations 2 - A11 Normal Landing ChecklistItem 13 · .PDF · 260 KBOperations 2 - A12 Expanded Landing ChecklistItem 14 · .PDF · 295 KBOperations 2 - A13 Missed Approach ProceduresItem 15 · .PDF · 265 KBOperations 2 - A14 Circuit BreakersItem 16 · .PDF · 186 KBOperations 2 - A15 Crew Flight And Duty TimesItem 17 · .PDF · 777 KBOperations 2 - A16 Excerpts From Previous Accident ReportsItem 18 · .PDF · 347 KBOperations 2 - A17 NWA Flt Ops General BulletinItem 19 · .PDF · 734 KBOperations 2 - A18 NWA Amdended Procedures and AOMItem 20 · .PDF · 271 KBOperations 2 - A19 NWA Simulator Instructor GuideItem 21 · .PDF · 56 KBOperations 2 - Factual Report of Group Chairman - Addenda/ErrataItem 22 · .PDF · 31 KBATC 3 - GUM Aircraft Accident PackageItem 23 · .PDF · 3.1 MBATC 3 - ZAU Aircraft Accident PackageItem 24 · .PDF · 3.6 MBAirworthiness Factual Report of Group ChairmanItem 25 · .PDF · 10 photos · 392 KBBoeing Survey ReportItem 26 · .PDF · 172 KBCorrespondence - Email Regarding On-Scene Gear CyclesItem 27 · .PDF · 44 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 28 · .PDF · 1.4 MBParty Submission - ALPAItem 29 · .PDF · 203 KBParty Submission - NWAItem 30 · .PDF · 64 KB

FAA reports on this event · 1

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