DCA17FA076

NTSB accident investigation · Mcdonnell Douglas MD80 · Ypsilanti, MI · March 8, 2017

Accident · Minor injuriesClass 1 · FieldFinal report
Date
March 8, 2017, 14:55 local (19:55 UTC)
Place
Ypsilanti, MI
Injuries
1 minor, 115 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N786TWMcdonnell Douglas MD80
Defining event
Takeoff-rejected takeoff: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report May 6, 2019
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
FAA, Boeing, ameristar
Safety recommendations
Yes
FAA report
20170308005569A
Case key
94839

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 jammed condition of the airplane's right elevator, which resulted from exposure to localized, dynamic wind while the airplane was parked and rendered the airplane unable to rotate during takeoff. Contributing to the accident were (1) the effect of a large structure on the gusting surface wind at the airplane's parked location, which led to turbulent gust loads on the right elevator sufficient to jam it, even though the horizontal surface wind speed was below the certification design limit and maintenance inspection criteria for the airplane, and (2) the lack of a means to enable the flight crew to detect a jammed elevator during preflight checks for the Boeing MD-83 airplane. Contributing to the survivability of the accident was the captain's timely and appropriate decision to reject the takeoff, the check airman's disciplined adherence to standard operating procedures after the captain called for the rejected takeoff, and the dimensionally compliant runway safety area where the overrun occurred.

Findings · 5

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.

Wind: high windEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentMcdonnell Douglas DC-9-83(MD-83): 1 caseAll aircraft: 112 casesProbable cause
Object/animal/substance: residence/buildingEnvironmental issues › Physical environment · Effect on equipmentMcdonnell Douglas DC-9-83(MD-83): 1 caseAll aircraft: 58 casesProbable cause
Meteorological servicesEnvironmental issues › Operating environment · Accuracy of related infoMcdonnell Douglas DC-9-83(MD-83): 1 caseAll aircraft: 4 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

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/01. On March 8, 2017, about 1452 eastern standard time, Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, a Boeing MD-83 airplane, N786TW, overran the departure end of runway 23L at Willow Run Airport, Ypsilanti, Michigan, after the captain executed a rejected takeoff. The 110 passengers and 6 flight crewmembers (two airline transport pilots and four flight attendants) evacuated the airplane via emergency escape slides. One passenger received a minor injury, and the airplane sustained substantial damage. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 121 as an on-demand charter flight and was destined for Washington Dulles International Airport, Dulles, Virginia. Visual flight rules conditions prevailed at YIP at the time of the accident.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/01. On March 8, 2017, about 1452 eastern standard time, Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, a Boeing MD-83 airplane, N786TW, overran the departure end of runway 23L at Willow Run Airport, Ypsilanti, Michigan, after the captain executed a rejected takeoff. The 110 passengers and 6 flight crewmembers (two airline transport pilots and four flight attendants) evacuated the airplane via emergency escape slides. One passenger received a minor injury, and the airplane sustained substantial damage. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 121 as an on-demand charter flight and was destined for Washington Dulles International Airport, Dulles, Virginia. Visual flight rules conditions prevailed at YIP at the time of the accident.

Aircraft

Registration
N786TW
Reported as
Mcdonnell Douglas MD80 (80)
Category
Airplane
Serial number
53123
Built
1992
Airframe hours
41,008.6
Engines
Pratt And Whitney JT8D-219, turbo jetPratt And Whitney JT8D-219, turbo jet
Damage
Substantial damage
Flight
Part 121
Operator
Ameristar Air Cargo, Inc., doing business as Ameristar and Ameristar Charters
Registered owner
Sierra American Corporation
Airworthiness certificate
Standard, Transport
Last inspection
December 30, 2016
Departed
KYIP · Ypsilanti, MI
Destination
KIAD · Chantilly, VA
Flight plan
IFR
Airport
KYIP · Willow Run International Airpo, runway 23L, 7,543 × 161 ft, concrete
Equipment
Stall warning system, Data recorder, Electronic flight bag or handheld device, Electronic primary flight display, Onboard weather

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
Check pilot
Age
41
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 31, 2017
Seat
Right
Restraint
3-point
Flight hours
8,660 total · 683 in this make and model · 7,240 as pilot in command · 50.4 in the last 90 days · 19.1 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
54
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 4, 2016
Seat
Left
Restraint
3-point
Flight hours
15,518 total · 4,596 in this make and model · 4,752 as pilot in command · 68 in the last 90 days · 30 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 35 knots, gusting 50
Visibility
10 statute miles
Temperature
52 °F, dew point 12 °F
Observed at
KYIP

Docket · 60

The files NTSB released with the investigation on April 11, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 122 MB in all.

Operations Group Chairman's Factual ReportItem 1 · .PDF · 2 photos · 1.9 MBOperations Attachment 1 - Interview SummariesItem 2 · .PDF · 634 KBOperations Attachment 2 - Witness StatementsItem 3 · .PDF · 3.0 MBOperations Attachment 3 - Flight Release PaperworkItem 4 · .PDF · 5.0 MBOperations Attachment 4 - Pilot InformationItem 5 · .PDF · 743 KBOperations Attachment 5 - Weight and Balance DocumentsItem 6 · .PDF · 2.8 MBOperations Attachment 6 - MD-83 Preflight Pictorial (Slide 14 excerpts)Item 7 · .PDF · 189 KBOperations Attachment 7 - Ameristar MD-83 ChecklistsItem 8 · .PDF · 394 KBOperations Attachment 8 - YIP Runway 23L Performance AnalysisItem 9 · .PDF · 237 KBOperations Attachment 9 - Boeing Flight Operations BulletinItem 10 · .PDF · 333 KBOperations Attachment 10 - FAA Response 17-125Item 11 · .PDF · 1.2 MBOperations Attachment 11 - YIP Simulator Test PlanItem 12 · .PDF · 1.0 MBOperations Attachment 12 - Ameristar Windshear Avoidance (AOM excerpts)Item 13 · .PDF · 566 KBOperations Attachment 13 - Ameristar RTO Procedures (AOM excerpts)Item 14 · .PDF · 251 KBOperations Attachment 14 - Taxi Checklist (AOM excerpt)Item 15 · .PDF · 224 KBOperations Attachment 15 - Party FormsItem 16 · .PDF · 714 KBOperations Addendum 1 - Load PlanItem 17 · .PDF · 1.0 MBFlight Data Recorder - Specialist's Factual ReportItem 18 · .PDF · 3.1 MBFlight Data Recorder - Attachment 1Item 19 · .CSV · 423 KBFlight Data Recorder - Attachment 2Item 20 · .CSV · 2.0 MBMeteorology Factual ReportItem 21 · .PDF · 4.4 MBAttachment 1 to the Meteorology Group Chairman's Factual ReportItem 22 · .PDF · 86 KBAttachment 2 to the Meteorology Group Chairman's Factual ReportItem 23 · .PDF · 221 KBAttachment 3 to the Meteorology Group Chairman's Factual ReportItem 24 · .PDF · 215 KBAttachment 4 to the Meteorology Group Chairman's Factual ReportItem 25 · .PDF · 144 KBAttachment 5 to the Meteorology Group Chairman's Factual ReportItem 26 · .PDF · 758 KBAttachment 6 to the Meteorology Group Chairman's Factual ReportItem 27 · .PDF · 145 KBAttachment 7 to the Meteorology Group Chairman's Factual ReportItem 28 · .PDF · 3.3 MBAttachment 8 to the Meteorology Group Chairman's Factual ReportItem 29 · .PDF · 577 KBAttachment 9 to the Meteorology Group Chairman's Factual ReportItem 30 · .PDF · 913 KBAttachment 10 to the Meteorology Group Chairman's Factual ReportItem 31 · .PDF · 162 KBKYIP Wind Study Simulation (Shelf Item)Item 32 · .PDF · 69 KBSystems Group Chairman's Factual ReportItem 33 · .PDF · 61 photos · 11.9 MBAttachment 1 to the Systems Group Chairman's Factual ReportItem 34 · .PDF · 959 KBAttachment 2 to the Systems Group Chairman's Factual ReportItem 35 · .PDF · 120 KBAttachment 3 to the Systems Group Chairman's Factual ReportItem 36 · .PDF · 1.9 MBAttachment 4 to the Systems Group Chairman's Factual ReportItem 37 · .PDF · 483 KBAttachment 5 to the Systems Group Chairman's Factual ReportItem 38 · .PDF · 37 KBUAS Aerial Imagery Factual - Hangar MappingItem 39 · .PDF · 925 KBUAS Aerial Imagery Factual-Hangar Mapping Attachment 1 - Orthomosaic Wreckage Map (Shelf Item)Item 40 · .PDF · 73 KBUAS Aerial Imagery Factual-Accident SiteItem 41 · .PDF · 2.9 MBUAS Aerial Imagery Factual-Accident Site Attachment 1 - Orthomosaic Wreckage Map (Shelf Item)Item 42 · .PDF · 73 KBUAS Aerial Imagery Factual-Accident Site Attachment 3 - Photo - Accident SiteItem 43 · .PDF · 1 photo · 247 KBUAS Aerial Imagery Factual-Accident Site Attachment 4 - Photo - Accident Site, Overhead ViewItem 44 · .PDF · 1 photo · 261 KBUAS Aerial Imagery Factual-Accident Site Attachment 5 - Photo - Accident Site, Side ViewItem 45 · .PDF · 1 photo · 256 KBUAS Aerial Imagery Factual-Accident Site Attachment 6 - Photo - Runway End and Tire MarksItem 46 · .PDF · 1 photo · 200 KBSecurity Video FileItem 47 · AVI · 20.5 MBMaintenance RecordsItem 48 · .PDF · 1.2 MBCockpit Voice Recorder - Group Chairman's Factual ReportItem 49 · .PDF · 1.3 MBGroup Chairman's Factual Report - StructuresItem 50 · .PDF · 25 photos · 15.1 MBSurvival Factors Group Chairman’s Factual ReportItem 51 · .PDF · 9 photos · 3.0 MBSurvival Factors Attachment 1 - Flight Attendant InterviewsItem 52 · .PDF · 74 KBSurvival Factors Attachment 2 – Flight Attendant StatementsItem 53 · .PDF · 4.0 MBSurvival Factors Attachment 3 – Zodiac Aerospace CMMItem 54 · .PDF · 318 KBAircraft PerformanceItem 55 · .PDF · 4 photos · 3.6 MBAircraft Performance ErratumItem 56 · .PDF · 18 KBParty Submission from BoeingItem 57 · .PDF · 1.4 MBParty Submission from AmeristarItem 58 · .PDF · 348 KBFlight Data Recorder Addendum 1 - Specialist's Factual ReportItem 59 · .PDF · 42 KBFlight Data Recorder Addendum 1 - Attachment 1Item 60 · .CSV · 14.2 MB

FAA reports on this event · 1

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