# NTSB MIA04IA056: Airbus Industrie A300F4-605R, N682FE, Fort Lauderdale, FL, March 11, 2004 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: March 11, 2004, 06:53 local (11:53 UTC) - Place: Fort Lauderdale, FL - Coordinates: 26.0725, -80.152496 - Nearby events: https://openairdocs.org/map.md?lat=26.0725&lon=-80.1525&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 20, 2005 - Report: Approved by Office Director - Parties: ALPA, Federal Express Corporation-Flight Safety, Airbus Industrie, FAA FSDO - NTSB case key (mKey): 58883 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04IA056 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58883/pdf - Page: https://openairdocs.org/ntsb/MIA04IA056 ## Probable cause The flight crews' inadvertent setting of the parking brake during flight resulting in the airplane being landed with the parking brake set and failure of all 8 main landing gear tires during the landing rollout. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, landing - flare/touchdown - parking brakes - inadvertent activation, flightcrew (cause) - landing gear,tire - failure,total ## Analysis The airplane had a failure of all eight main landing gear tires during the landing roll on runway 27. According to the flight crew stated prior to departure they were given paperwork to perform an alternate brake system test in-flight. At the top of descent they began the test. The First Officer read the procedure and the Captain performed the tasks. The Captain stated that during the test she observed brake pressures of 2,100 psi on the left and 2,500 psi on the right. She was use to observing 2,500 psi on both during this test. She performed additional testing on her own to troubleshoot the 2,100 psi reading on the left system. She then returned the system to normal and made a write-up in the aircraft's maintenance log. The First Officer was the pilot flying and after the test they descended and approached to land at Fort Lauderdale. During the approach they performed the approach and landing checks and checked the brake system. They were using manual braking for the landing. The touchdown was proper, and the airplane immediately began to decelerate. The captain asked the First Officer if he was braking and he said no. The controller then informed them that he was rolling the equipment and when they asked why, he stated because of smoke and fire. The Captain performed the emergency evacuation checklist and the First Officer opened the aircraft door and deployed the slide. They then exited the airplane. A pilot in another airplane reported to the controller that the aircraft's tire prints at the point the airplane touched down " looked like their brakes were locked or something." Examination of the landing runway (27 Right) after the incident revealed four sets of heavy skid marks (two per bogie) that started from the initial touchdown point and were continuous to the aircraft's final resting point. There was evidence of wheel rim contact, from both the left and right main gear wheels, beginning about 500-600 feet after touchdown and continuing to the location where the aircraft came to rest. The first set of two skid marks started at about 1,200 feet from the threshold of the runway and was consistent with right main landing gear touchdown first. The total distance for the right skid was 2,383 feet. The second set of two skid marks started about 81 feet further down the runway and was consistent with a left main landing gear touchdown. Examination of the aircraft revealed the following: all eight main landing gear tires had blown, deflated, and come apart. The damage was confined to the side of the tires that was in contact with the runway and all eight tires were worn down to the wheel assembly; there were no flat spots or other indications of damage on the opposite side of each tire. All eight wheel assemblies were symmetrically worn down about 10 percent. All eight brakes, wheel speed transducers shafts, and brake fans were damaged; there was no damage to either the left or right bogie beams. Prior to changing the tires and removing the airplane from the runway, Federal Express maintenance personnel performed a Built In Test Equipment (BITE) test on the Braking and Steering Control Unit (BSCU). The BITE test revealed 12 fault codes. Airbus accomplished a test flight in order to reproduce the BITE fault codes that were downloaded from the incident aircraft's BSCU. The test flight was done in France on an A300-600 aircraft where the following scenario was simulated: "Aircraft in flight, landing gear extended, parking brake set ON. This test did trigger the same 12 fault codes on the BSCU. Post incident testing of the brake system components on the incident airplane showed no evidence of failure or malfunction of any of the system components. ## Factual narrative History of Flight On March 11, 2004, about 0653 eastern standard time, an Airbus Industrie A300F4-605R, N682FE, operated by Federal Express Corporation as flight 1954, a Title 14 CFR Part 121 scheduled domestic cargo flight, had a failure of all eight main landing gear tires, during the landing roll on runway 27 right at the Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida. Visual meteorological conditions prevailed. An instrument flight rules flight plan was filed. The airplane received minor damage. The two airline transport-rated pilots reported no injuries. The flight had originated from Newark, New Jersey, at 0430. The Captain stated to the NTSB Operations Group during an interview that she deadheaded to FLL on March 9, 2004, to begin the flight sequence. She had never met, nor flown with, the FO before this sequence of flights. They flew together from FLL to EWR, the night before the landing incident. There was a crew break at EWR but no hotel was provided. She stated that she slept for 1½ hours and the FO slept for about 2 hours. They gathered the flight paperwork and proceeded to the aircraft together. The airplane preflight was accomplished. The flight was catered. She stated that the #2 battery had been replaced. They were given the paperwork for the alternate brake check. They started to pushback. They then started to taxi and had not moved 10 feet when they received a #2 battery overheat warning. It took about an hour for maintenance to resolve the problem. Again, the airplane was pushed back and a takeoff was made on runway 4L. Inbound to EWR, she heard popping and clicking sounds in the cockpit, perhaps caused by the pressurization system. She stated that she decided to try to narrow down these sounds on the next flight leg. On the flight leg from EWR to FLL, leaving 10,000 feet, a vibration could be felt in the floorboard every 3 to 5 seconds. She wrote it up in the maintenance log. It could also be felt in the circuit breaker wall and other places. The flight was normal at FL 350. At the top of descent, the FAA alternate brake check was accomplished. She stated that she gave the written procedure to the first officer to read while she accomplished the procedure. The First Officer had never seen the form. It was daylight by this time. The BRK-A/SKID switch was pulled out and positioned to the ALTN-OFF position. The BRAKE FAIL light came on. The brake pedals were then depressed. A chime was heard. She stated that when the brake pedals are depressed, you get "ECAM." Usually the brake pressures were about 2,500 psi; however, this time, the left brake pressure indication was 2,100 and the right brake pressure indication was 2,500. During a normal preflight, the alternate brake system is checked. This was accomplished in FLL and EWR. Both times the brake pressures were symmetrical with 2,500 PSI indicated on the gauge but during this in-flight check, they were not. She stated that she wrote it up in the maintenance log. The BRK-A/SKID switch was then returned to the NORM/ON position. The procedure was discussed with the First Officer. He had never seen this procedure before. She stated that she wanted to trouble shoot the system. The BRK-A/SKID switch was then selected to ALTN/ON, like she does on the preflight. A chime was audible. The BRK-A/SKID switch was then selected to NORM/ON. She stated that she wrote it up as she saw it and then asked the First Officer to review the write-up. The First Officer was the flying pilot. A descent clearance was obtained and a descent was initiated. The checklist was accomplished by the pilot-not-flying, the captain, at 18,000 feet. Everything was normal. They landed on runway 27R at FLL, running about an hour late. The Before Landing checklist was accomplished. At the point where it says, brakes checked, she normally points to the items while she is looking at them. The BRK-A/SKID switch was NORM/ON and there was no pressure indication on the alternate system pressure gauges. She checked the REL bars on the ECAM; they were there and she called, "checklist complete." Before landing, she commented that the runway was clear. The First Officer made a nice landing in the touchdown zone. She called, "spoilers deployed," and asked the First Officer, "are you braking?" He said, no. The deceleration was noticeable. Tower said they were "rolling the equipment." She asked the First Officer to ask the tower what they saw. "Smoke and Fire," was the answer. When the airplane came to a stop, she set the parking brake, moved the throttles to idle, and positioned the fuel levers "down." The First Officer got out of his seat and unlocked the cockpit door. She ran through the evacuation checklist by shutting things down. She noticed emergency equipment arriving in front of the airplane. She told the First Officer that we will evacuate. The First Officer pulled the APU fire handle. The First Officer asked to fire the "bottle" but she said, no. The First Officer asked which door to open. She said, the right side, and then told him not to open it until she said so. She also told the First Officer to make sure he had the HAZMAT paperwork. She then turned the battery switch back on and asked the tower if there was still fire. She never got a reply from the tower. The battery switch was turned back off. The cabin door only partially opened. The First Officer had to push the door open. The slide started to deploy and inflated normally. She never did smell any smoke or see any fire. After the evacuation, the First Officer walked over to a fireman and said, "Here's the HAZMAT paperwork." The Captain stated that after landing, she expected a normal rollout but got uncommanded braking instead. She had performed the in-flight alternate braking system operational check before but it had been a while. She has been on the A-300 almost 9 years. She has performed the procedure more than once but she was not sure how many times. She had never written one up before. The brake pressures were always about 2,500 psi and symmetrical. This has never been a problem on the ground either. No other abnormal indications were noted. Both the Captain and First Officer confirmed that indications were normal on landing. The Captain stated that the parking brake was not set until after landing. She stated that she did not set the parking brake in flight. She positioned the BRK-A/SKID switch from NORM/ON to ALTN/ON and got a "ding" and a message. She made note of the brake pressure and then positioned the BRK-A/SKID switch back to NORM/ON. She did not recall how many chimes there were during the test. She stated that there were no unrelated abnormals during this brake checking sequence. The brake pressures went back to zero and were zero on the brake check before landing. She stated that it was not "challenge and response" on the landing check. I said, "brakes checked," and the first officer verified it. She stated that she did not set the parking brake until after the airplane was stopped and the evacuation was being accomplished. She stated that there is no formal training on this procedure. "We have a flight test department." If we are going to do it, we should see it in the simulator. The form should spell out what lights and what ECAM indications you should get. It only asks, "pressure or no pressure?" On the Before Landing checklist, "Brakes Checked," you are looking for no pressure, zero pressure. On rollout, there was "some releasing." She stated that there were no landing gear system warnings. It looked like everything was going fine. She did not use the brakes but she always has her feet on the pedals. The winds were calm, light. No auto brakes were used; they discussed that they were going to use manual braking. She asked if the first officer was braking. She stated that it felt like a "non event," n ## Aircraft - Registration: [N682FE](https://openairdocs.org/aircraft/N682FE), registered now, S/N 0800, built 1999 (OpenAirDocs) - Reported make and model: Airbus Industrie A300F4-605R - Registry model: [Airbus Industrie A300 F4-605R](https://openairdocs.org/model/airbus-industrie-a300-f4-605r) (registry code 3930327) (OpenAirDocs) - Registry engine: [GE CF6-80 series](https://openairdocs.org/engine/ge-cf6-80-series) (registry code 30025, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 0800 - Airframe hours: 7648 - Engines: General Electric CF6-80C2A5F 60000 lbs thrust turbo fan - Damage: Minor damage - Fire: On-Ground - Flight: Part 121 - Operator: Federal Express Corp - Registered owner: State Street Bank and Trust - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, March 7, 2004, 26 hours before - Departed: KEWR, NEWARK, NJ - Destination: KFLL, Fort Lauderdale, FL - Flight plan: IFR - Airport: FLL, Fort Lauderdale/Hollywood, runway 27R, 9,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: none; airline transport, flight engineer; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review October 3, 2003; seat: left; flight hours: 13,000 total, 3,000 in this make and model, 124 in the last 90 days, 32 in the last 30 days, 6 in the last 24 hours - Co-pilot; age 48; injuries: none; flight engineer, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review December 14, 2003; seat: right; flight hours: 8,000 total, 600 in this make and model, 81 in the last 90 days, 17 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 50 °F - Altimeter: 30.20 inHg - Observed at: KFLL, 1 nm away From the NTSB's public API. 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