# NTSB DCA99MA007: Boeing 737-200, Atlanta, GA, November 1, 1998 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Major investigation · Final report - Date: November 1, 1998, 18:48 local (23:48 UTC) - Place: Atlanta, GA - Location: 33.6367° N, 84.4279° W: Placed by OpenAirDocs at HARTSFIELD/JACKSON ATLANTA INTL (ATL), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.6367&lon=-84.4279&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 13 minor, 92 uninjured - Status: Completed, report February 20, 2003 - Report: Approved by Office Director - NTSB office: Major Investigations Division - NTSB case key (mKey): 45278 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA99MA007 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45278/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=45278 - Page: https://openairdocs.org/ntsb/DCA99MA007 ## Probable cause (1) the capping of the incorrect hydraulic line by mechanics, which led to the failure of hydraulic system A; (2) the mechanics' lack of experience working with the Boeing 737 hydraulic system; and (3) the maintenance controller's failure to ascertain more information regarding the leaking hydraulic line before instructing the mechanics to cap the line and deactivate the right thrust reverser. Contributing to the cause of the accident were (1) the asymmetric directional control resulting from the deactivation of the right thrust reverser; (2) the depletion of the left and right inboard brake accumulator pressure because of the flight crew's use of the rudder pedals with only the left thrust reverser to control the direction of the airplane down the runway; (3) the failure of the right outboard brake because the airplane was slowed without the use of the left and right inboard brakes and was traveling at a higher-than-normal speed and with heavy gross weight; (4) the failure of the right outboard brake after one of the right outboard pistons overtraveled and unported its o-ring, allowing system B hydraulic fluid to deplete and the left outboard brake to fail; and (5) the mechanics' improper use of the illustrated parts catalog for maintenance and troubleshooting and the maintenance controller's failure to use the appropriate documents for maintenance and troubleshooting. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, climb - maintenance,service of aircraft/equipment - improper, company maintenance personnel (cause) - hydraulic system,line - failure (cause) - procedure inadequate, other maintenance personnel (cause) - inadequate surveillance,inadequate procedure, company/operator mgmt (cause) - Airframe/component/system failure/malfunction, landing - roll - hydraulic system - not available, flightcrew (contributing factor) - landing gear,normal brake system - failure (contributing factor) - Loss of control - on ground/water, landing - roll - thrust reverser - asymmetrical (contributing factor) - directional control - diminished, flightcrew (contributing factor) - On ground/water collision with object, landing - roll - object - other (contributing factor) ## Analysis The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine of the Boeing 737-200 during a postflight inspection at William B. Hartsfield Atlanta International Airport (ATL), Georgia. AirTran mechanics at ATL identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. They found the part in the illustrated parts catalog (IPC), which was not designed as a troubleshooting document and does not contain sufficient detail for such use. One of the mechanics telephoned an AirTran maintenance controller in Orlando, Florida, for further instructions. The mechanics who initially identified the source of the leak had little experience working on the Boeing 737 because they had worked for ValuJet Airlines, which flew DC-9s only, until ValuJet and AirTran merged in September 1997. On the basis of the information provided by the mechanic, and without questioning his description of the line or verifying the part number that he had provided against the IPC or some other appropriate maintenance document, the maintenance controller instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. Depletion of system A hydraulic fluid activated the hydraulic low-pressure lights in the cockpit, which alerted the flight crew that the airplane had a hydraulic problem. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch. ## Factual narrative HISTORY OF FLIGHT On November 1, 1998, about 1734:48 eastern standard time (all times in this brief are eastern standard time based on a 24-hour clock), AirTran Airways flight 867, a Boeing 737-223, Irish registration EI-CJW, crashed after departing the side of runway 9L at William B. Hartsfield International Airport (ATL), Atlanta, Georgia, during an emergency landing. Of the 2 flight crewmembers, 3 flight attendants, and 100 passengers on board, 2 passengers received serious injuries, and 14 passengers received minor injuries. The airplane was substantially damaged. Flight 867 was operating under the provisions of 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from ATL to Dallas?Ft. Worth International Airport, Texas. Flight 867 was the airplane's second flight of the day. AirTran flight 890, from William P. Hobby Airport, Houston, Texas, to ATL, arrived at 1320. At the conclusion of flight 890, the first officer of that flight performed a postflight check of the airplane and discovered a fluid leak coming from the number two (right) engine. Two AirTran mechanics (referred to in this brief as the first and second mechanics), who were working the first shift of the day, reported in postaccident interviews that they opened the engine cowling and found a chafed hydraulic line with a "misting" or "spray" of hydraulic fluid leaking from the line. They inspected the hydraulic pump and associated areas and did not find any other leaks. To specifically identify the leaking line, the mechanics reported that they operated the right thrust reverser on the ground without running the engine. (This test was specified in the Boeing 737 Maintenance Manual.) The mechanics stated that they followed the leaking line to the hydraulic pump and found that the leak was from a pressure line that appeared to go to the thrust reverser. This line did not have an identification number, so the mechanics referred to the illustrated parts catalog (IPC) to identify the line by its part number. The first mechanic reported that a replacement line was not available, but caps of the proper size were available for repairing the line. About 1415, the first mechanic telephoned an AirTran maintenance controller at Orlando International Airport (MCO), Florida, to report that the hydraulic leak was on the pressure line going to the number 2 (right) thrust reverser at the service panel where the thrust reverser cable goes over the thrust reverser pressure line. The first mechanic also told the maintenance controller the part number for the line that needed to be replaced. In a postaccident interview, the maintenance controller stated that he did not reference the IPC during the telephone call because he thought he was familiar with the location of the leak based on the mechanic's description of the problem. The maintenance controller stated that he discussed the leaking hydraulic line with the AirTran manager of maintenance at MCO, who agreed with the controller that the line could be repaired rather than replaced if parts were available. The maintenance controller then instructed the mechanic to cap the line and deactivate the associated thrust reverser according to AirTran's Minimum Equipment List (MEL) procedures. (The MEL procedures allowed one thrust reverser to be inoperative provided it was deactivated and secured closed and a placard was placed in the cockpit indicating that the thrust reverser was inoperative.) Further, the maintenance controller told the mechanic that the damage to the hydraulic line would be further assessed at the airplane's next scheduled maintenance visit. According to the flight discrepancy sheet issued by maintenance control, the right engine thrust reverser hydraulic leak was to be repaired on or before November 4, 1998. After capping the hydraulic pressure line, the first-shift mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems. No leaks were reported. The mechanics did not start the right engine as part of the leak check, but they were not required by AirTran procedures to do so. Two additional AirTran mechanics (referred to in this brief as the third and fourth mechanics), who were working the second shift of the day, were also involved in the repair operation. The third mechanic arrived early for his shift and assisted the first mechanic in deactivating the thrust reverser because the first mechanic had not previously performed this task on a 737. About 1530, the mechanics told the maintenance controller that they had deactivated the thrust reverser. At the end of their shift, the first and second mechanics briefed the third and fourth mechanics on the status of the repair operation and told them the work that remained to complete the repair. The second-shift mechanics accomplished the remaining tasks, serviced the hydraulic fluid level, and performed the daily walkaround check (a brief visual check of specific areas of the airplane to detect any obvious discrepancies.) About 1600, the third mechanic signed off on the repair and indicated that the airplane was ready for flight. Cockpit voice recorder (CVR) information indicated that, about 1710, flight 867 departed ATL. The captain was the flying pilot, and the first officer was the nonflying pilot. About 1719:57, the captain stated, "hydraulic pumps are [unintelligible word], I hope that's in error." About 3 seconds later, the first officer indicated, "I hope that's an error, too." Flight data recorder (FDR) data showed that the airplane was at an altitude of approximately 18,000 feet about this time. About 1721:50 and 1721:55, the captain stated, "well, there goes the A system" and "looks like we're gonna be going back to Atlanta." About 1722:34, the first officer notified air traffic control that the airplane needed to return to ATL. The controller asked whether there were any problems, and the first officer responded, about 1722:54, "…not at this time. we're having erroneous hydraulic system indication…we'll…keep you advised." About 1723:56, the flight crew initiated AirTran's non-normal procedures for the loss of system A hydraulic pressure when the first officer stated, "system A flight control switches [unintelligible word] goes standby rudder?" and the captain replied, "you go ahead and do those." (AirTran's Aircraft Operations Manual, volume 1, indicates that the first action for the loss of system A hydraulic pressure is to select the standby rudder.) About 1724:35, the captain instructed the first officer to tell the air traffic controller that they would need a "long straight in" for landing. The first officer then informed the controller, who offered the flight crew the use of runway 9L or 9R; the flight crew chose runway 9L because it was longer. (Runway 9L is 11,889 feet long and 150 feet wide.) About 1726:54, the first officer stated, "…all right ground spoilers inboard spoilers nosewheel [steering] inoperative, thrust reversers are standby pressure, inboard brakes accumulator only…." About 1728:12, the first officer notified the air traffic controller that the field was in sight and that the airplane would be able to clear the runway but a tug would be needed for towing afterward. About 1728:29, the first officer called for the approach briefing. The flight crew was also responsible for accomplishing the other tasks on AirTran's checklist for the loss of hydraulic system A. These tasks included setting the approach airspeed for a flaps 15 landing (the CVR indicated that the captain was planning an approach airspeed of 155 knots), extending the leading edge flaps and slats with the use of the standby hydraulic system, and extending the trailing edge flaps electrically. Further, the flight crew had to extend the landing gear manually and plan the landing witho ## Aircraft - Registration: EICJW (not matched to a registry record) - Reported make and model: Boeing 737-200 - Category: Airplane - Serial number: 21355 - Airframe hours: 45857 - Engines: P&W JT8D-17 14000 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: Airtran Airways Inc - Registered owner: Ge Capital Aviation Services , Ltc - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, September 26, 1998 - Departed: ATL - Destination: DALLAS, TX - Flight plan: IFR - Airport: ATL, William B Hartsfield Intl, runway 9L, 11,889 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; commercial, airline transport, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review June 5, 1998; seat: left; toxicology performed; flight hours: 15,000 total, 79 in the last 90 days, 40 in the last 30 days - Co-pilot; age 34; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: right; toxicology performed; flight hours: 4,976 total, 60 in the last 90 days, 19 in the last 30 days ## Weather - Conditions: Visual (VMC), Dusk - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 162 °F, dew point 124 °F - Altimeter: 29.00 inHg ## Docket (56 files) The files NTSB released with the investigation on January 9, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=45278. 24.1 MB in all. - Operations/Human Performance 2 - Group Chairman Factual Report (item 1, .PDF, 680 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468515&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Group%20Chairman%20Factual%20Report-Redacted.PDF - Operations/Human Performance 2 - Attachment 1 - Interview Summaries (item 2, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468516&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%201%20-%20Interview%20Summaries-Redacted.PDF - Operations/Human Performance 2 - Attachment 2 - Emergencies and Safety Issues, Chapter Six, Flight Operations Manual Excerpt (item 3, .PDF, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151952&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%202%20-%20Emergencies%20and%20Safety%20Issues,%20Chapter%20Six,%20Flight%20Operations%20Manual%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 3 - Forms and Reports, Chapter Eight, Flight Operations Manual Excerpt (item 4, .PDF, 612 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151953&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%203%20-%20Forms%20and%20Reports,%20Chapter%20Eight,%20Flight%20Operations%20Manual%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 4 - Exhaust, Section 2.78, Boeing 737 Minimum Equipment List Excerpt (item 5, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151954&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%204%20-%20Exhaust,%20Section%202.78,%20Boeing%20737%20Minimum%20Equipment%20List%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 5 - ATL Airport Diagram (item 6, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151955&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%205%20-%20ATL%20Airport%20Diagram-Master.PDF - Operations/Human Performance 2 - Attachment 6 - Aircraft Systems, AOM Volume 1 Excerpt (item 7, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151956&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%206%20-%20Aircraft%20Systems,%20AOM%20Volume%201%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 7 - Non-Normal, Aircraft Operations Manual Excerpt (item 8, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151957&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%207%20-%20Non-Normal,%20Aircraft%20Operations%20Manual%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 8 - Hydraulic Power, QRH Excerpt (item 9, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151958&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%208%20-%20Hydraulic%20Power,%20QRH%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 9 - Flight Standards, AOM Volume 1 Excerpt (item 10, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151959&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%209%20-%20Flight%20Standards,%20AOM%20Volume%201%20Excerpt%20-Master.PDF - Operations/Human Performance 2 - Attachment 10 - Aircraft Variation Highlights, AOM Volume 1 Excerpt (item 11, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151960&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2010%20-%20Aircraft%20Variation%20Highlights,%20AOM%20Volume%201%20Excerpt-Master.PDF - Operations/Human Performance 2 - Attachment 11 - Load Plan and Weight & Balance (item 12, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468517&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2011%20-%20Load%20Plan%20and%20Weight%20%26%20Balance-Redacted.PDF - Operations/Human Performance 2 - Attachment 12 - DE-fuel Receipts (item 13, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468518&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2012%20-%20DE-fuel%20Receipts-Redacted.PDF - Operations/Human Performance 2 - Attachment 13 - Flight Papers (item 14, .PDF, 653 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151963&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2013%20-%20Flight%20Papers-Master.PDF - Operations/Human Performance 2 - Attachment 14 - Alcohol Tests and Drug Screens (item 15, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468519&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2014%20-%20Alcohol%20Tests%20and%20Drug%20Screens-Redacted.PDF - Operations/Human Performance 2 - Attachment 15 - Transcription of Air Traffic Control Voice Recordings (item 16, .PDF, 864 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468520&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2015%20-%20Transcription%20of%20Air%20Traffic%20Control%20Voice%20Recordings-Redacted.PDF - Operations/Human Performance 2 - Attachment 16 - Automated Radar Tracking System (ARTS) Tracking Data and Plot (item 17, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468521&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2016%20-%20Automated%20Radar%20Tracking%20System%20(ARTS)%20Tracking%20Data%20and%20Plot-Redacted.PDF - Operations/Human Performance 2 - Attachment 17 - ATL Surface Weather Observations (item 18, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151967&FileExtension=.PDF&FileName=Operations%2FHuman%20Performance%202%20-%20Attachment%2017%20-%20ATL%20Surface%20Weather%20Observations-Master.PDF - Survival Factors 6 - Group Chairman Factual Report (item 19, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468522&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Group%20Chairman%20Factual%20Report-Redacted.PDF - Survival Factors 6 - Appendix A - Photographs (item 20, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151969&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Appendix%20A%20-%20Photographs-Master.PDF - Survival Factors 6 - Photo. 1 - View of the left side of AirTran Flight 867 Note: L2 door and its close proximity to the ground. (item 21, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151970&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%201%20-%20View%20of%20the%20left%20side%20of%20AirTran%20Flight%20867%20%20Note%3A%20L2%20door%20and%20its%20close%20proximity%20to%20the%20ground.-Master.PDF - Survival Factors 6 - Photo. 2 - View of the right side of AirTran flight 867 Note: The gully that the airplane traversed and the distance between the R1 exit and the ground. (item 22, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151971&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%202%20-%20View%20of%20the%20right%20side%20of%20AirTran%20flight%20867%20%20%20Note%3A%20The%20gully%20that%20the%20airplane%20traversed%20and%20the%20distance%20between%20the%20R1%20exit%20and%20the%20ground.-Master.PDF - Survival Factors 6 - Photo. 3 - View of the R2 emergency evacuation slide that was found on the taxiway adjacent to the airplane wreckage. Note: An overwing hatch was found on top of the evacuation slide. (item 23, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151972&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%203%20-%20View%20of%20the%20R2%20emergency%20evacuation%20slide%20that%20was%20found%20on%20the%20taxiway%20adjacent%20to%20the%20airplane%20wreckage.%20%20Note%3A%20%20An%20overwing%20hatch%20was%20found%20on%20top%20of%20the%20evacuation%20slide.-Master.PDF - Survival Factors 6 - Photo. 4 - View of the placard on the (manual) L2 emergency evacuation slide bonnet Note: Item 2 states; "SLIDE INFLATES AUTOMATICALLY" (item 24, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151973&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%204%20-%20View%20of%20the%20placard%20on%20the%20(manual)%20L2%20emergency%20evacuation%20slide%20bonnet%20%20Note%3A%20%20Item%202%20states;%20%20%22SLIDE%20INFLATES%20AUTOMATICALLY%22-Master.PDF - Survival Factors 6 - Photo. 5 - View of the R1 emergency exit door. Note: The door is partially opened. (item 25, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151974&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%205%20-%20View%20of%20the%20R1%20emergency%20exit%20door.%20%20Note%3A%20%20The%20door%20is%20partially%20opened.-Master.PDF - Survival Factors 6 - Photo. 6 - View of oxygen masks that were found deployed at the forward flight attendants jumpseat. (item 26, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151975&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%206%20-%20View%20of%20oxygen%20masks%20that%20were%20found%20deployed%20at%20the%20forward%20flight%20attendants%20jumpseat.-Master.PDF - Survival Factors 6 - Photo. 7 - View of the airplane's interior cabin Note: The oxygen masks that deployed at seats 23 and 25 D, E, and F (item 27, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151976&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%207%20-%20View%20of%20the%20airplane%27s%20interior%20cabin%20%20%20Note%3A%20%20The%20oxygen%20masks%20that%20deployed%20at%20seats%2023%20and%2025%20D,%20E,%20and%20F-Master.PDF - Survival Factors 6 - Photo. 8 - View of the tray table for seat 28D, Note: The lever that secures the tray table barely overlaps the top of the tray table. (item 28, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151977&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%208%20-%20View%20of%20the%20tray%20table%20for%20seat%2028D,%20%20Note%3A%20%20The%20lever%20that%20secures%20the%20tray%20table%20barely%20overlaps%20the%20top%20of%20the%20tray%20table.-Master.PDF - Survival Factors 6 - Photo. 9 - View of the emergency evacuation slide that was installed at the L2 door on flight 867 (item 29, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151978&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%209%20-%20View%20of%20the%20emergency%20evacuation%20slide%20that%20was%20installed%20at%20the%20L2%20door%20on%20flight%20867-Master.PDF - Survival Factors 6 - Photo. 10 - View of the L2 slide inflation bottle pressure gage Note: The gage pressure is in the green at 30 psi. (item 30, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151979&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Photo.%2010%20-%20View%20of%20the%20L2%20slide%20inflation%20bottle%20pressure%20gage%20%20Note%3A%20%20The%20gage%20pressure%20is%20in%20the%20green%20at%2030%20psi.-Master.PDF - Survival Factors 6 - Appendix B (item 31, .PDF, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468523&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Appendix%20B-Redacted.PDF - Survival Factors 6 - Appendix C (item 32, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151981&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Appendix%20C-Master.PDF - Survival Factors 6 - Appendix D - AirTran Fleet Campaign Directive and Engineering Bulletin and Airplane 470 and 467 Log Pages (item 33, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468524&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Appendix%20D%20-%20AirTran%20Fleet%20Campaign%20Directive%20and%20Engineering%20Bulletin%20and%20Airplane%20470%20and%20467%20Log%20Pages-Redacted.PDF - Systems 9 - Group Chairman Factual Report (item 34, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468525&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report-Redacted.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photographs (item 35, .PDF, 7 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151984&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photographs-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photo 1. Damage to Nose of Aircraft (item 36, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151985&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photo%201.%20Damage%20to%20Nose%20of%20Aircraft-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photo 2. View from inside E&E Bay showing damage from nose gear. (item 37, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151986&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photo%202.%20View%20from%20inside%20E%26E%20Bay%20showing%20damage%20from%20nose%20gear.-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photo 3. View of hydraulic lines on right outboard engine looking inboard. (Digital Photo) (Pump supply (r) disconnected to facilitate pump removal) (item 38, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151987&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photo%203.%20View%20of%20hydraulic%20lines%20on%20right%20outboard%20engine%20looking%20inboard.%20(Digital%20Photo)%20(Pump%20supply%20(r)%20disconnected%20to%20facilitate%20pump%20removal)-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photo 4. Close-up view of figure 3. (1) Hydraulic case drain return (as found), (c) Hydraulic pump pressure, (r) Hydraulic pump supply. (item 39, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151988&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photo%204.%20Close-up%20view%20of%20figure%203.%20(1)%20Hydraulic%20case%20drain%20return%20(as%20found),%20(c)%20Hydraulic%20pump%20pressure,%20(r)%20Hydraulic%20pump%20supply.-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photo 5. Trail of hydraulic fluid from right outboard brake. (Digital Photo) (item 40, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151989&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photo%205.%20Trail%20of%20hydraulic%20fluid%20from%20right%20outboard%20brake.%20(Digital%20Photo)-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix A - Photo 6. Right outboard brake showing heat damage. (item 41, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151990&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20A%20-%20Photo%206.%20Right%20outboard%20brake%20showing%20heat%20damage.-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix B - Accident Map (item 42, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151991&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20B%20-%20Accident%20Map-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix C - Cockpit Documentation (item 43, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151992&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20C%20-%20Cockpit%20Documentation%20-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix D - B737 System Schematics (item 44, .PDF, 820 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151993&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20D%20-%20B737%20System%20Schematics%20-Master.PDF - Systems 9 - Group Chairman Factual Report - Appendix E - Hydraulic Line Materials Laboratory Report (item 45, .PDF, 681 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468526&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20E%20-%20Hydraulic%20Line%20Materials%20Laboratory%20Report-Redacted.PDF - Systems 9 - Group Chairman Factual Report - Appendix F - Hydraulic Pump Teardown Report (item 46, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468527&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20F%20-%20Hydraulic%20Pump%20Teardown%20Report%20-Redacted.PDF - Systems 9 - Group Chairman Factual Report - Appendix G - Brake Assembly Teardown Report (item 47, .PDF, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151996&FileExtension=.PDF&FileName=Systems%209%20-%20Group%20Chairman%20Factual%20Report%20-%20Appendix%20G%20-%20Brake%20Assembly%20Teardown%20Report-Master.PDF - Flight Data Recorder 10 - Group Chairman Factual Report (item 48, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469736&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Group%20Chairman%20Factual%20Report-Redacted.PDF - Maintenance Records 11 - Group Chairman Factual Report (item 49, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151998&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Group%20Chairman%20Factual%20Report-Master.PDF - Maintenance Records 11 - Attachment A - Parts Catalog 29-11-00-13 (item 50, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40151999&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%20A%20-%20Parts%20Catalog%2029-11-00-13-Master.PDF - Maintenance Records 11 - Attachment B - MEL 78-01-01 (item 51, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152000&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%20B%20-%20MEL%2078-01-01-Master.PDF - Maintenance Records 11 - Attachment C - Maintenance Manual 78-32-01 (item 52, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152001&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%20C%20-%20Maintenance%20Manual%2078-32-01-Master.PDF - Maintenance Records 11 - Attachment D - Maintenance Manual 12-12-0 (item 53, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152002&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%20D%20-%20Maintenance%20Manual%2012-12-0-Master.PDF - Maintenance Records 11 - Attachment E - Parts Catalog 78-31-0-26 (item 54, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152003&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%20E%20-%20Parts%20Catalog%2078-31-0-26-Master.PDF - Cockpit Voice Recorder 12 - Group Chairman Factual Report (item 55, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469738&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Group%20Chairman%20Factual%20Report-Redacted.PDF - Aircraft Performance 13 - Group Chairman Factual Report (item 56, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469739&FileExtension=.PDF&FileName=Aircraft%20Performance%2013%20-%20Group%20Chairman%20Factual%20Report-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.