# NTSB DCA05MA095: Boeing 747-200, N627US, Agana, August 19, 2005 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Major investigation · Final report - Date: August 19, 2005, 14:18 local (04:18 UTC) - Place: Agana - Coordinates: 13.484911, 144.796865 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=13.4849&lon=144.7969&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 2 minor, 338 uninjured - Status: Completed, report December 30, 2008 - Report: Approved by Office Director - NTSB office: Major Investigations Division - Parties: AMFA, ALPA - NWA, FAA, Boeing, NWA - NTSB case key (mKey): 62281 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA05MA095 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62281/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62281 - Page: https://openairdocs.org/ntsb/DCA05MA095 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Wheels up landing, landing - landing gear,gear indicating system - activated - checklist - not followed, flightcrew (cause) - gear extension - not verified, flightcrew (cause) - 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](https://openairdocs.org/deregistered/N627US-2008-07-16), registration cancelled 2008-07-16, S/N 21709, built 1979 (OpenAirDocs) - Reported make and model: BOEING 747-200 - Registry model: [Boeing 747-251B](https://openairdocs.org/model/boeing-747-251b) (registry code 1384892) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: 21709 - Airframe hours: 95270 - Engines: Pratt & Whitney JT9D-7Q 53000 lbs thrust turbo fan; Pratt & Whitney JT9D-7Q 53000 lbs thrust turbo fan; Pratt & Whitney JT9D-7Q 53000 lbs thrust turbo fan; Pratt & Whitney JT9D-7Q 53000 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: none; 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 - Co-pilot; age 46; injuries: none; 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 - Flight engineer; age 61; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20050819020349A](https://openairdocs.org/incident/20050819020349A), Aug 19, 2005: Boeing 747251B, Agana, Guam, Substantial damage. (-23) About 2 miles out on a visual approach to pgum, pilot reported a problem, initiated a go-around and requested to circle off shore. Thereafter, he… ## Docket (30 files) The files NTSB released with the investigation on May 2, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62281. 17.1 MB in all. - Operations 2 - Factual Report of Group Chairman (item 1, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294461&FileExtension=.PDF&FileName=Operations%202%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Operations 2 - List Of Attachments (item 2, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242032&FileExtension=.PDF&FileName=Operations%202%20-%20List%20Of%20Attachments-Master.PDF - Operations 2 - A1 Flight Crew Statements (item 3, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242047&FileExtension=.PDF&FileName=Operations%202%20-%20%20A1%20Flight%20Crew%20Statements-Master.PDF - Operations 2 - A2 Landing Gear Systen Description (item 4, .PDF, 353 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242007&FileExtension=.PDF&FileName=Operations%202%20-%20%20A2%20Landing%20Gear%20Systen%20Description-Master.PDF - Operations 2 - A3 Landing Gear Ops And Indications (item 5, .PDF, 785 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242033&FileExtension=.PDF&FileName=Operations%202%20-%20A3%20Landing%20Gear%20Ops%20And%20Indications-Master.PDF - Operations 2 - A4 Alternate Landing Gear Operation (item 6, .PDF, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242010&FileExtension=.PDF&FileName=Operations%202%20-%20%20A4%20Alternate%20Landing%20Gear%20Operation-Master.PDF - Operations 2 - A5 Manual Nose Gear Extension (item 7, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242011&FileExtension=.PDF&FileName=Operations%202%20-%20A5%20Manual%20Nose%20Gear%20Extension-Master.PDF - Operations 2 - A6 Procedures Red Light ON After Gear Extension (item 8, .PDF, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242012&FileExtension=.PDF&FileName=Operations%202%20-%20A6%20Procedures%20Red%20Light%20ON%20After%20Gear%20Extension-Master.PDF - Operations 2 - A7 Boeing Ops Manual Bulletin (item 9, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242013&FileExtension=.PDF&FileName=Operations%202%20-%20A7%20Boeing%20Ops%20Manual%20Bulletin-Master.PDF - Operations 2 - A8 Previous Flight Crew Statements (item 10, .PDF, 675 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294462&FileExtension=.PDF&FileName=Operations%202%20-%20A8%20Previous%20Flight%20Crew%20Statements-Redacted.PDF - Operations 2 - A9 NTSB Operator Accident Report (item 11, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471382&FileExtension=.PDF&FileName=Operations%202%20-%20A9%20NTSB%20Operator%20Accident%20Report-Master.PDF - Operations 2 - A10 Boeing Ops Manual Excerpt (item 12, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242037&FileExtension=.PDF&FileName=Operations%202%20-%20A10%20Boeing%20Ops%20Manual%20Excerpt-Master.PDF - Operations 2 - A11 Normal Landing Checklist (item 13, .PDF, 260 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242038&FileExtension=.PDF&FileName=Operations%202%20-%20A11%20Normal%20Landing%20Checklist-Master.PDF - Operations 2 - A12 Expanded Landing Checklist (item 14, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242039&FileExtension=.PDF&FileName=Operations%202%20-%20A12%20Expanded%20Landing%20Checklist-Master.PDF - Operations 2 - A13 Missed Approach Procedures (item 15, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242040&FileExtension=.PDF&FileName=Operations%202%20-%20A13%20Missed%20Approach%20Procedures-Master.PDF - Operations 2 - A14 Circuit Breakers (item 16, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242041&FileExtension=.PDF&FileName=Operations%202%20-%20A14%20Circuit%20Breakers-Master.PDF - Operations 2 - A15 Crew Flight And Duty Times (item 17, .PDF, 777 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242042&FileExtension=.PDF&FileName=Operations%202%20-%20A15%20Crew%20Flight%20And%20Duty%20Times-Master.PDF - Operations 2 - A16 Excerpts From Previous Accident Reports (item 18, .PDF, 347 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242045&FileExtension=.PDF&FileName=Operations%202%20-%20A16%20Excerpts%20From%20Previous%20Accident%20Reports-Master.PDF - Operations 2 - A17 NWA Flt Ops General Bulletin (item 19, .PDF, 734 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294464&FileExtension=.PDF&FileName=Operations%202%20-%20A17%20NWA%20Flt%20Ops%20General%20Bulletin-Redacted.PDF - Operations 2 - A18 NWA Amdended Procedures and AOM (item 20, .PDF, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300924&FileExtension=.PDF&FileName=Operations%202%20-%20A18%20NWA%20Amdended%20Procedures%20and%20AOM-Master.PDF - Operations 2 - A19 NWA Simulator Instructor Guide (item 21, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300929&FileExtension=.PDF&FileName=Operations%202%20-%20A19%20NWA%20Simulator%20Instructor%20Guide-Master.PDF - Operations 2 - Factual Report of Group Chairman - Addenda/Errata (item 22, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300930&FileExtension=.PDF&FileName=Operations%202%20-%20Factual%20Report%20of%20Group%20Chairman%20-%20Addenda%2FErrata-Master.PDF - ATC 3 - GUM Aircraft Accident Package (item 23, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471384&FileExtension=.PDF&FileName=ATC%203%20-%20GUM%20Aircraft%20Accident%20Package-Master.PDF - ATC 3 - ZAU Aircraft Accident Package (item 24, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471385&FileExtension=.PDF&FileName=ATC%203%20-%20ZAU%20Aircraft%20Accident%20Package-Master.PDF - Airworthiness Factual Report of Group Chairman (item 25, .PDF, 10 photos, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270196&FileExtension=.PDF&FileName=Airworthiness%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Boeing Survey Report (item 26, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302771&FileExtension=.PDF&FileName=Boeing%20Survey%20Report-Master.PDF - Correspondence - Email Regarding On-Scene Gear Cycles (item 27, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471383&FileExtension=.PDF&FileName=Correspondence%20-%20Email%20Regarding%20On-Scene%20Gear%20Cycles-Master.PDF - Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 28, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291291&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Party Submission - ALPA (item 29, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471386&FileExtension=.PDF&FileName=Party%20Submission%20-%20ALPA-Master.PDF - Party Submission - NWA (item 30, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305157&FileExtension=.PDF&FileName=Party%20Submission%20-%20NWA-Master.PDF From the NTSB's public API. 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