FTW98FA380

NTSB accident investigation · Boeing 767-34AF · Houston, TX · September 11, 1998

Accident · No injuriesField investigationFinal report
Date
September 11, 1998, 06:24 local (11:24 UTC)
Place
Houston, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N316UPBoeing 767-34AF
Weather
Instrument (IMC) · Night
Status
Completed · report February 26, 2007
Report
Approved by Office Director
Parties
United Parcel Service, Boeing Aircraft, Federal Aviation Administration, Independent Pilots Association
FAA report
19980911034919A
Case key
43916

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The flight crew's decision to land with convective activity over the airport with a prevailing crosswind to a quartering tailwind, on an ungrooved, flooded runway, which resulted in hydroplaning and a loss of directional control. Factors contributing to the accident were: prevailing dark night conditions; severe weather conditions associated with a major tropical storm, such as convective activity, strong crosswinds, the quartering tailwind, and torrential rain. Also contributing to the accident were the operator's failure to provide the flight crew with up-to-date weather forecasts, in-flight weather advisories, and pertinent NOTAMS relating to the safe operation of the flight.

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.

In flight encounter with weatherApproach - faf/outer marker to threshold (ifr)
Light condition - dark nightFactor
Dispatch procedures - inadequateDispatcherFactor
Weather condition - thunderstormFactor
Weather condition - crosswindFactor
Weather condition - tailwindFactor
Missed approach - performedFlightcrew
Weather condition - rainFactor
Loss of control - on ground/waterLanding - roll
Airport facilities,runway/landing area condition - inaccurateFactor
Airport facilities,runway/landing area condition - waterFactor
Airport facilities,runway/landing area condition - otherFactor
Weather evaluation - misjudgedFlightcrewCause
Aircraft performance,hydroplaning conditionFactor
Directional control - not maintainedFlightcrewCause

Analysis

The night cargo flight was dispatched from the company's main hub into a known area of potentially severe weather, which was influenced by a stationary front and Tropical Storm "Frances." The terminal forecast provided by the operator to their flight crew was 2-days old. The flight crew was not properly briefed on the forecasted weather conditions for the destination airport, and were not provided with all of the adverse weather information and NOTAMS affecting their route of flight and their destination airport. The flight crew missed the first approach to runway 17R due to strong crosswinds. The flight was subsequently vectored for a Category 1 ILS approach to runway 35L. Level 4 to 5 convective activity with tops to 42,000 feet were present over the destination airport at the time of the mishap. The flight crew configured the airplane for an "autoland" approach with the auto-brakes set for maximum braking. A strong crosswind to a quartering tailwind prevailed during the flight's final approach and landing. The airplane touched down 17-feet left of the centerline of the 9,000-foot long ungrooved concrete runway, which was reported to be partly flooded due to its low crown. The auto-pilot was never disconnected by the flight crew and no attempt was made by the flight crew to abort the landing during the accident sequence. The tower had previously reported standing water a the intersection of runway 17R and taxiway Delta during the first approach. The investigation revealed that the runway condition check was conducted by driving a vehicle over the runway centerline for the full length of the runway. The investigation team was on the runway when another torrential rain shower moved across the airport. The team was able to observe a rapid manifestation of water pooling on the runway, mostly away from the centerline. The depth of the water pooling was measured to be at least 7- inches. The investigation team concluded that the issued "standing water" report failed to indicate the severity of the amount of water actually flooding the runway. Heavy rain showers, sometimes described as "torrential" prevailed throughout the area at the time of the accident. Another weather station, located 29 miles to the southeast, reported 7.64 inches of rain from the tropical storm. Witnesses reported the airplane produced a "heavy rooster tail of water" as soon as it touched down on runway 35L. Airport Rescue and Fire Fighting personnel that responded to the accident site, reported that despite the location of their fire house, approximately 1/4-mile across the ramp from the resting place of the airplane, the aircraft was not visible due to the heavy rain that prevailed at the time of the mishap. Some of the first responders reported that "it was raining sideways" at the time of the mishap. Tire marks, similar to "steam cleaning" were found on the concrete surface of the runway, from the touchdown point to the point where the airplane exited the left side of the 150-foot wide runway, were consistent with the tires being in a state of hydroplaning. Nose wheel steering was found to be operational during the landing sequence. Main tire pressures were found to be within inflation limits (185 to 200 PSI). Two of the main tires (no. 3 and no. 7) were damaged and deflated during the accident sequence. One tire showed some discoloration (bluing). On-board avionics test equipment did not record any faults with the autoland system during the accident flight. Examination and bench testing of the eight brake assemblies did not reveal any anomalies. The eight wheel transducers were also tested by the manufacturer and were found to be within limits. The anti-skid/auto-brake control unit was also tested and found fully functional. Flight data recorder data, as well as tire prints made by the nose wheel tire on the runway revealed that the inter-connect between the rudder and the nose wheel assembly attempted to steer the aircraft toward the localizer course. All navigational aids associated with the instrument approach were reported as operating normal during the two approaches. There was sufficient fuel on board to proceed to the alternate airport.

Factual narrative

History of flight

On September 11, 1998, at 0624 central daylight time, a twin-engine Boeing 767-34AF airplane, N316UP, operating as UPS Flight 774, was substantially damaged following a loss of control during the landing roll at the Ellington Field Airport near Houston, Texas. The two-airline transport rated pilots were not injured. The airplane was owned and operated by United Parcel Service (UPS) Co., of Louisville, Kentucky, under 14 Code of Federal Regulations Part 121. Dark night instrument meteorological conditions prevailed for the cargo flight for which an instrument flight rules (IFR) flight plan was filed. The flight was dispatched from the UPS main hub in Louisville, Kentucky, at 0357, for the scheduled one hour and fifty minute flight to Ellington Field. The flight was scheduled to arrive at Ellington Field at 0554.

The captain was the "flying pilot" during the accident flight. The first instrument landing system (ILS) approach to runway 17R was missed at 0551, due to the prevailing high crosswind conditions at the airport. After performing a missed approach, the flight was vectored around weather for a second approach to the same runway. During the vectoring sequence, the controller suggested the ILS approach for runway 35L to avoid thunderstorms transiting near the final approach course for runway 17R. The crew accepted the suggestion and the airplane was subsequently vectored for the Category 1 ILS approach to runway 35L.

The crew stated that all three autopilot systems were functioning, and the airplane was configured for an "autoland" Cat I approach and landing to runway 35L, with the auto-brakes set for maximum braking (setting number 4). The ILS 3-degree glide slope was intercepted and captured at a radar altitude of 2,300 feet. The captain reported that he was closely monitoring the flight controls and instruments during the approach and landing sequence. Both crew members concurred that the approach was stabilized and uneventful, and visual contact was made with the runway environment as the airplane descended through 1,000 feet MSL. The flight data recorder (FDR) revealed that above 500 feet radar altitude, the autoland system established a nose right crab angle of 11 to 12 degrees.

The winds issued by the tower to flight 774 while on short final were from 090 degrees at 15 knots, gusting to 23 knots. The flight crew acknowledged that no windshear alerts were received during the two approaches.

The crew reported that the touchdown was normal. FDR data revealed that the airplane touched down on the right main gear with a 3-degree bank into the right crosswind. The captain stated that the airplane touched down slightly left of centerline. FDR data revealed that the nose landing gear touched down 17 feet to the left of the centerline. Tire tracks on the runway revealed that the airplane remained downwind of the runway centerline after touchdown. FDR data revealed that rudder deflection during the initial landing rollout moved from 0.3 degrees right to 25 degrees right (maximum deflection) within about 9 seconds.

The captain further stated that he engaged the thrust reversers as soon as the nose gear was on the ground; however, there was "no feel of deceleration" from either the brakes or the reversers.

The flight crew did not initiate any attempt to abort the landing. Despite the windshield wipers operating at the "high" setting, both crewmembers concurred that the forward visibility deteriorated drastically on short approach and during the landing roll (the operator did not maintain the optional cockpit windshield hydrophobic coating treatment available from the aircraft manufacturer).

The flight crew reported that the airplane's autoland system continued to attempt to correct the ground track of the airplane towards the localizer course (centerline of the runway) during the landing roll. The FDR data revealed that the flight crew did not disconnect the auto-pilot during the accident sequence. FDR information revealed that the airplane touched down at a ground speed of 149 knots (144 calibrated). The reference speed (Vref) for the approach was calculated at 143 knots IAS.

Several witnesses on the ground observed the landing of the airplane. Most witnesses concurred that the airplane produced "a heavy rooster tail of water" as soon as it touched down on the runway. The flight crew of a Miami Air Flight aircraft, which was operating under the call sign "Brisbane 290," was on the ground awaiting a clearance, and reported to the tower that "the landing airplane [UPS 774] looks like he just fish-tailed sideways off-the-runway." The same flight crew alerted the tower that the airplane "had gone dark" and was on the side of the runway.

The investigation revealed four major shortcomings in the UPS Pre-Departure weather briefing packages: published runway advisories were not relayed; runway or field conditions were not current; the RAMTAF terminal forecast for the destination airport was not current; and only certain adverse weather advisories were provided to the flight crew.

Other damage

The taxiway marker for taxiway Bravo was destroyed by impact with the right wing of the airplane. Seven runway lights and three taxiway lights were either sheared or knocked down by the airplane during the accident sequence. Runway 35L/17R remained closed until the airplane was recovered to the airport ramp, approximately 3 days after the accident.

Personnel information

The 41-year old captain was issued an airline transport pilot certificate on June 24, 1994. He had been employed with UPS Airlines since March 21, 1988. He was upgraded to captain on July 6, 1994. Prior to his captain assignment, he functioned as a first officer in the Boeing 767. The captain had accumulated a total of 5,600 hours, of which 3,200 hours were in the Boeing 757/767. His last proficiency check was completed 14 days prior to the accident, on August 28, 1998. His last medical examination was completed on June 16, 1998, and he was issued an FAA first class medical certificate without any waivers or limitations. The captain had flown a total of 11 hours in the preceding 30 days, 47 hours in the preceding 90 days, and 360 hours in the preceding 12 months. Prior to joining UPS, the captain was an officer with the United States Air Force, where he had accumulated around 600 hours in the KC-135 and 1,300 hours in the Cessna T-37.

The first officer, age 53, held an airline transport pilot certificate, issued by the FAA with an airplane multiengine land rating and type ratings in the Boeings 707 and 720. The first officer was hired by UPS Airlines on March 21, 1988, as a flight engineer on the DC-8 aircraft. The first officer had accumulated a total of 5,950 flight hours, of which 2,270 were in the Boeing 757/767 aircraft. His last FAA first class medical certificate was issued on January 5, 1998, with a limitation for wearing eyeglasses to correct a near vision condition. The first officer completed his last proficiency check in the Boeing 757/767 on August 28, 1998. He had flown 99 hours in the preceding 90 days, 37 hours in the preceding 30 days, with 482 hours in the preceding 12 months. Prior to joining UPS, the first officer was also an officer in the United States Air Force, where he flew KC-135 tankers.

Both crewmembers had completed the required cockpit resource management (CRM) training from the operator. The investigation revealed that the operator did not address a hydroplaning scenario in any of their syllabi for crew training.

The flight crew was not properly briefed on forecasted weather conditions for their destination and were not provided with all the adverse weather information affecting the route of flight. The flight crew failed to recognize that their terminal forecast or RAMTAF was two days old, nor did they contact UPS flight dispatch for any upda

Aircraft

Registration
N316UP
Reported as
Boeing 767-34AF
Category
Airplane
Serial number
27744
Airframe hours
2,810
Engine
General Electric CF6-80C2B, turbo jet
Damage
Substantial damage
Flight
Part 121
Registered owner
United Parcel Service
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 23, 1998
Departed
SDF · Louisville, KY
Destination
EFD · Houston, TX
Flight plan
IFR
Airport
EFD · Ellington Field, runway 35L, 9,000 × 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
5,600 total · 3,200 in this make and model · 47 in the last 90 days · 11 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
100° at 18 knots, gusting 25
Visibility
4 statute miles
Lowest ceiling
700 ft broken
Temperature
79 °F, dew point 79 °F
Altimeter
29.54 inHg
Observed at
EFD

FAA reports on this event · 1

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