DCA96MA029

NTSB accident investigation · Boeing 747-136 · Jamaica, NY · December 20, 1995

Accident · Serious injuriesClass 1 · MajorFinal report
Date
December 20, 1995, 11:36 local (16:36 UTC)
Place
Jamaica, NY
Injuries
1 serious, 24 minor, 443 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N605FFBoeing 747-136
Weather
Instrument (IMC) · Day
Status
Completed · report December 2, 1996
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19951220041539A
Case key
11008

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 captain's failure to reject the takeoff in a timely manner when excessive nosewheel steering tiller inputs resulted in a loss of directional control on a slippery runway. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air, Inc., and the Boeing Commercial Airplane Group and the inadequate fidelity of B-747 flight training simulators for slippery runway operations contributed to the cause of this accident. The captain's reapplication of forward thrust before the airplane departed the left side of the runway contributed to the severity of the runway excursion and damage to the airplane.

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.

Loss of control - on ground/waterTakeoff - roll/run
Airport facilities,runway/landing area condition - snow coveredFactor
Airport facilities,runway/landing area condition - icyFactor
Nosewheel steering - excessivePilot in commandFactor
Directional control - not maintainedPilot in commandFactor
Procedure inadequateCompany/operator managementFactor
Procedure inadequateManufacturerFactor
Facility inadequateFactor
On ground/water collision with objectTakeoff - aborted
Aborted takeoff - delayedPilot in commandCause
Throttle/power control - improper use ofPilot in commandFactor
Object - airport sign/marker
Object - other

Analysis

The captain initiated a takeoff on runway 4L, which was covered with patches of ice and snow. The wind was from 330 degrees at 11 knots. Before receiving an 80-knot call from the 1st officer, the airplane began to veer to the left. Subsequently, it went off the left side of the runway and collided with signs and an electric transformer. Investigation revealed evidence that the captain had overcontrolled the nosewheel steering through the tiller, then applied insufficient or untimely right rudder inputs to effect a recovery. The captain abandoned an attempt to reject the takeoff, at least temporarily, by restoring forward thrust before the airplane departed the runway. The current Boeing 747 operating procedures provide inadequate guidance to flightcrews regarding the potential for loss of directional control at low speeds on slippery runways with the use of the tiller. Current Boeing 747 flight manual guidance was inadequate about when a pilot should reject a takeoff following some indication of a lack of directional control response. Improvements in the slippery runway handling fidelity of flight simulators used for Boeing 747 pilot training were considered to be both needed and feasible. (See: NTSB/AAR-96-04 for detailed information.)

Factual narrative

On December 20, 1995, at 1136 eastern standard time, a Boeing 747-136, N605FF, operated by Tower Air, Inc., sustained substantial damage during an aborted takeoff at the John F. Kennedy International Airport, Jamaica, New York. The two airline transport rated pilots and one flight engineer were not injured; nor were there injuries to eleven of the flight attendants or two cockpit jump seat occupants. One flight attendant received serious injuries. There were 24 minor injuries among the 441 passengers. Instrument meteorological conditions prevailed, and an IFR flight plan was filed for the flight, which was destined for Miami, Florida. The passenger/cargo flight was being conducted under 14 CFR Part 121.

The airplane, Flight 41, was de-iced at the gate, prior to passenger boarding. It was towed from the gate about 1036, and de-iced again, prior to commencing taxiing. Flight 41 was cleared to taxi to runway 4L, which was the active runway for departures, while snow removal was in progress on runway 31. Flight 41 was cleared for takeoff at 1136. Shortly after initiating the takeoff, the pilot reported that the airplane veered to the left of centerline. He attempted to correct the change in direction with rudder and steering tiller, but the airplane continued to turn left. The airplane exited the left side of the runway about 2100 feet from the start of the takeoff roll. The pilot stated that he initiated an aborted takeoff before the airplane exited the side of the runway, by retarding the throttles to idle and applying maximum braking.

After the airplane departed the runway, the number 4 engine impacted a concrete structure, containing electrical wires, and the entire pylon separated from the wing. As the airplane continued in soft terrain, the right wing landing gear and nose gear collapsed. The airplane came to rest between two taxiways, approximately 4800 feet from the start of the takeoff roll.

The captain determined that there was no sign of fire and the injuries to passengers were not serious; therefore, he elected to not order an emergency evacuation. The removal of passengers was conducted in an orderly manner by airport personnel.

Runway 4L had been plowed and sanded about 1.5 hours prior to the accident, and an estimated 22 aircraft had departed on that runway. The wind was reported from the control tower as 330 degrees at 11 knots, as Flight 41 was cleared for takeoff. The pilot reported that he was able to see the runway centerline during line-up, even though there was packed snow covering portions of the runway.

Additional Persons (Continued)

Michael Young Pratt & Whitney 400 Main Street M/S162-24 East Hartford, CT 06106

Mr. Chris Witkowski Association of Flight Attendants 1625 Massachusetts Ave., NW Washington, DC 20036-2212

Aircraft

Registration
N605FF
Reported as
Boeing 747-136
Category
Airplane
Serial number
20271
Airframe hours
24,921
Engine
P&W JT9D-7A, 46,950 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Tower Air
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 29, 1993
Departed
JFK
Destination
MIA · Miami, FL
Flight plan
IFR
Airport
JFK · John F. Kennedy Intl, runway 4L, 11,351 × 150 ft, asphalt

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
53
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
May 7, 1995
Seat
Left
Flight hours
16,455 total · 2,905 in this make and model · 190 in the last 90 days · 62 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
56
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Flight hours
17,734 total · 4,804 in this make and model · 178 in the last 90 days · 11 in the last 30 days · 0 in the last 24 hours
Role
Flight engineer
Age
34
Certificates
Private, Flight engineer
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Last flight review
March 9, 1995
Seat
Rear
Flight hours
4,609 total · 2,799 in this make and model · 160 in the last 90 days · 56 in the last 30 days · 10 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
330° at 11 knots
Visibility
1.5 statute miles
Lowest ceiling
700 ft broken
Temperature
25 °F, dew point 21 °F
Altimeter
29.00 inHg
Observed at
JFK

FAA reports on this event · 1

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