LAX97FA276

NTSB accident investigation · Lockheed L-1011-385-1-15 · Honolulu, HI · August 8, 1997

Accident · Serious injuriesField investigationFinal report
Date
August 7, 1997, 19:35 local (Aug 8, 1997, 05:35 UTC)
Place
Honolulu, HI
Injuries
1 serious, 58 minor, 246 uninjured
Damage
Minor damage
Phase of flight
Takeoff
Aircraft
N740DALockheed L-1011-385-1-15
Weather
Visual (VMC) · Dusk
Status
Completed · report February 11, 2000
Report
Approved by Office Director
FAA report
19970807045599A
Case key
29627

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 cumulative distance taxied immediately prior to takeoff that precipitated an excessive heat buildup in the tires and resulted in the bead separation of a single tire during the takeoff roll. The absence of cockpit procedures/directives or monitoring equipment to identify this condition was a factor in the accident. Contributing to the accident was the unavailability of two emergency exits due to the malfunction of the 2R and 4R emergency doors

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.

Airframe/component/system failure/malfunctionTakeoff - roll/run
Landing gear,brake temperature system - not installedFactor
Procedures/directives - not availableFactor
Landing gear,tire - overtemperatureCause
Unsafe/hazardous condition warning - not available
Landing gear,tire - exploded
Aborted takeoff - initiatedPilot in commandFactor
FireTakeoff - aborted
Landing gear,normal brake system - fire
Miscellaneous/otherStanding - engine(s) not operating
Evacuation - initiatedPilot in command
Door,emergency exit - activated
Misc eqpt/furnishings,slides - activated
Door,emergency exit - jammed
Door,emergency exit - malfunction

Analysis

After maintenance completed troubleshooting and the aircraft taxied out for the final time, the aircraft had taxied 11.3 miles within a 3-hour period. There was no temperature gauge or tabular data available that could have informed the crew that heat buildup resulting from taxi distance was now at a level that potentially threatened the integrity of the tires. During the takeoff roll, the 3F tire exploded, resulting in vibration, shudder, and yaw. The sudden instability, combined with a phantom C1 cargo door light, caused the Captain to abort. The abort was initiated about Vr (165 knots) with approximately 6,000 feet of runway remaining. As the aircraft came to a stop, the nose wheels were 164 feet short of the overrun area for runway 8R. A brake fire began while the aircraft was stopping and the captain directed an emergency evacuation. The 2R and 4R doors failed to open, and the 4L and 3L doors were not used due to their proximity to the fire and smoke. The 4R door was jammed by a broken piece of backboard, and the 2R door malfunctioned due to a partially broken counterbalance spring. The flight attendant who attempted to open the 2R door did not attempt to manually lift the door. All evacuations were made through the 1L, 1R, 2L, and 3R doors. Firefighters had difficulty communicating with the flight crew and in verifying the total number onboard because the airline's passenger count does not include lap children. A total of 56 passengers and 2 flight attendants were treated for minor injuries, while 1 passenger received a broken ankle. All injuries were attributed to the use of the slides. Passengers failed to follow flight attendants and attempted to evacuate with their carryons. The airline did not effectively supervise the passengers after the evacuation and several began walking toward an active runway. An inspection of the 3R tire showed bead separation had occurred. The estimated bead temperatures during the takeoff roll reached between 350 and 400 degrees Fahrenheit. The bead begins to degrade between 250 and 280 degrees Fahrenheit.

Factual narrative

History of flight

On August 7, 1997, at 1935 hours Hawaiian standard time, Delta Airlines Flight 54, a Lockheed L-1011-385-1-15, N740DA, aborted takeoff on runway 8R at the Honolulu, Hawaii, International Airport. A wheel/brake fire ensued as the aircraft came to a stop, and 1 passenger sustained serious injuries during the subsequent emergency evacuation, while another 59 received minor injuries. The aircraft sustained minor damage and the remaining 245 occupants were not injured. The aircraft was operated by Delta Airlines, Inc., as a scheduled domestic passenger flight from Honolulu to Atlanta, Georgia, under 14 CFR Part 121. The flight blocked out from the gate about. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed.

According to the airline maintenance records, the APU and the A channel of the area overheat system were inoperative when the crewmembers arrived at the aircraft. The dispatcher's records showed that the aircraft departed the gate at 1627 and proceeded to the end of 8R. During the initial taxi out the left wing duct fail light illuminated. The captain completed the checklist and the light went out; however, later in the taxi the light came on again. In view of these facts, the captain elected to return to the gate, arriving back there at 1655. The passengers were deplaned, maintenance was given the aircraft, and troubleshooting began at 1722. Maintenance personnel started all three engines and taxied out to runway 8R for an engine run. The overheat controller was replaced, the aircraft was again returned to the gate and, at 1845, the passengers and crew reboarded.

The flight attendants reported that, during the initial takeoff roll, dozens of soda cans spilled from the forward left storage cabinet into the number three cross-aisle when two retaining latches malfunctioned. The takeoff roll continued without further incident until reaching V1 (155 knots), when the captain noted the illumination of the door caution light on the pilot's caution and annunciator warning panel (PCAWP). He announced to the crew that he intended to continue the takeoff. Identification of the door causing the pilot's caution light to illuminate can only be made from the flight engineer's annunciator panel. The C1 cargo door was subsequently identified by the flight engineer.

About a second or so later, the captain felt the aircraft began to vibrate, shudder, and then begin a yaw to the left. He also perceived that the aircraft was settling to the left and heard what he described as "popping sounds." At this point, he decided that it would be unsafe to attempt a liftoff. The abort was initiated about Vr (165 knots) with approximately 6,000 feet of runway remaining. He slowed the aircraft by using full braking and reverse thrust. He corrected the left yaw with asymmetric brake and rudder inputs.

The first officer stated that he assisted the captain by also applying the brakes with about 2,000 feet of runway remaining. He also reported their aborted takeoff to the control tower while the abort was in progress.

Next, the flight attendants reported that a trash cart separated from its attachment fitting as the aircraft continued to decelerate. The cart began rolling down the aisle until it was stopped by one of the flight attendants. The cart brakes, which serve as a secondary latch, were set but did not prevent the cart from rolling.

As the aircraft came to a stop, the nose wheels were 164 feet short of the overrun area for runway 8R. At this point, the second officer reminded the captain that the brakes would likely be very hot and suggested that an evacuation of the aircraft should be considered.

The first officer contacted the tower requesting that fire and rescue personnel and equipment be dispatched.

The captain was about to direct an evacuation when someone in the back of the aircraft shouted, "fire." Upon hearing that, the captain immediately ordered an evacuation and the second officer said, "abandon the aircraft" to the OBL (on board leader). The captain completed the evacuation checklist and activated the evacuation horn. After the horn sounded, he visually confirmed that the flight attendants were opening the doors and deploying the evacuation slides.

After securing the cockpit with reference to the checklist, the cockpit crew went into the cabin to assist the flight attendants with the evacuation.

The two control tower specialists, working in the midfield tower, stated that they watched as the aircraft taxied into position and held on runway 8R. After the pilot was cleared for takeoff, the aircraft began its takeoff roll. As the aircraft approached the midfield point, both controllers reported hearing a loud boom. They also observed smoke and flames emanating from beneath the aircraft. When the aircraft was finally stopped at the end of the runway, flames remained visible. They observed emergency rescue vehicles rolling on taxiway RA by the time the aircraft halted.

Injuries to persons

According to the airline, 56 passengers and 2 flight attendants were treated for minor abrasions or smoke inhalation at the airport. A single passenger received a broken ankle and was transported to Queens hospital. Most of these injuries were sprains and abrasions that were sustained due to the use of the slides.

Damage to aircraft

After the accident, a Federal Aviation Administration (FAA) inspector arrived at the aircraft to oversee the investigation and the removal of the aircraft from the runway prior to the arrival of the Safety Board investigator. An airline mechanic documented the aircraft as follows: The 2R door was opened halfway with girt bar engaged, the slide pulled out halfway, and the emergency handle pulled into the full detent position. There was no evidence that the 3L door had been opened. The 4R door had opened approximately 2 inches with the girt bar engaged. The emergency handle was found in the stowed position. (Doors are numbered from fore to aft and then as left or right.)

In the cockpit, all ignition switches were off, the boost pumps were on, the throttles were at idle, and the fire T-handles were pulled. The flaps were at 14 degrees, the spoilers were down, there was minor damage to right inboard leading edge slat, and the 3R brake line was severed. The right engine was inspected for FOD; however, none was found. (Brakes and wheels are numbered from the left to right and then as front or rear.)

An inspection of the C1 door revealed no physical damage or other anomalies associated with the door latching mechanism or proximity sensor.

The 3R brake line was fractured and the leading edge slat had minor impact damage and black smears, both in the vicinity of the 3F tire. There were black smears on the fractured brake line. The 3F tire was fragmented. The 3F fuse plugs were intact.

The 2L slide was found to have partially deflated. When maintenance personnel inspected it, they discovered it had a slow leak.

The 4R slide backboard was cracked and a piece of the backboard was found lying in the forward doorsill.

Aircraft information

The dispatch records show that, as the aircraft reached the takeoff point on the runway, it was at its maximum gross weight for takeoff of 510,000 pounds and was carrying 183,000 pounds of fuel on board.

All eight main gear tires use an independent anti-skid sensing and control that are independent of each other. The anti-skid system is designed to deactivate as the aircraft's speed drops below 13 to 17 knots.

There is no cockpit monitoring system to warn of excessive heat buildup in the tires. In addition, there are no charts or warnings in the pilot's manuals to indicate how extended taxi distances can affect tire integrity.

The aircraft was manufactured with brake temperature gauges as standard equipment; however, the airline declined the gauges and

Aircraft

Registration
N740DA
Reported as
Lockheed L-1011-385-1-15 (L-1011-385)
Category
Airplane
Serial number
193C-1244
Airframe hours
60,686
Engine
Rolls-Royce RB211-524B4I, 41,000 lbs thrust, turbo fan
Damage
Minor damage
Fire
On-Ground
Flight
Part 121
Registered owner
Delta Air Lines Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 1, 1997 · 84 hours before
Departed
HNL · HI
Destination
ATL · Atlanta, GA
Flight plan
IFR
Airport
HNL · Honolulu International, runway 8R, 12,000 × 200 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
20,000 total · 2,000 in this make and model

Weather

Conditions
Visual (VMC) · Dusk
Wind
60° at 8 knots
Visibility
12 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
HNL

FAA reports on this event · 1

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