MIA96IA039

NTSB incident investigation · Boeing 747-212B · Amsterdam, Netherlands · December 10, 1995

Incident · No injuriesIncident investigationFinal report
Date
December 10, 1995
Place
Amsterdam, Netherlands
Injuries
306 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N616FFBoeing 747-212B
Weather
Instrument (IMC) · Day
Status
Completed · report July 11, 1996
Report
Approved by Office Director
Case key
37917

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

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Probable cause

The failure of the captain to maintain a level wings attitude during a go-around resulting in the right wing dragging on the ground.

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.

Dragged wing,rotor,pod,float or tail/skidMissed approach (ifr)
Weather condition - fog
Missed approach - performedPilot in command
Aircraft handling - improperPilot in commandCause

Analysis

The captain was flying the aircraft as the flight made a ILS approach to runway 19R. During the landing flare a fog bank rolled over the runway and he lost sight of the runway. A go-around was initiated. The digital flight data recorder showed that as the go-around was initiated the roll attitude of the aircraft increased from wings level to 24 degrees right wing down over 5 seconds. The radio altimeter increased from 1.8 feet to 29.2 feet over the same 5 second period. Recorded radar data showed the aircraft veered off to the right and flew a course parallel to the runway during the go-around. The flight returned for another approach and after an uneventful approach and landing on runway 19R, parked at the gate. After parking at the gate, the flight crew was informed by ground personnel that the No. 4 engine nacelle and right wing tip were damaged. Debris from the No. 4 engine nacelle was found on the right side of the runway, about 1400 meters from the threshold. No scrape marks were found on the runway.

Factual narrative

On December 10, 1995, about 0945 Universal Time Coordinated [UTC], N616FF, a Boeing 747-212B, operated by Tower Air, Inc., as flight No. 069, a 14 CFR Part 121 scheduled international passenger flight, from Bombay, India, to Amsterdam, Netherlands, dragged the right wig tip and the No. 4 engine nacelle during a missed approach on runway 19R at Schiphol Airport, Amsterdam, Netherlands. Instrument meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The airplane sustained minor damage, and the airline transport-rated captain, first officer, flight engineer, 1 extra crew, 14 flight attendants and 288 passengers reported no injuries. The flight had originated from Bombay, India, the same day about 0045.

The flight crew stated the captain was flying the instrument landing system approach (ILS) to runway 19R. Upon reaching the decision height the runway environment was in sight and the approach was continued. During the landing flare, fog rolled in and the crew lost sight of the runway. A missed approach was initiated and the flight received radar vectors for another ILS approach to runway 19R. The second approach and landing was uneventful and the aircraft was parked at the gate. The crew was then notified by ground personnel that the No. 4 engine nacelle and right wing tip had made ground contact. Airport personnel stated they found components from the No. 4 engine nacelle on the right side of runway 19R, about 1400 meters from the runway threshold. No scrape marks were located on the runway surface.

Transcripts of communications between air traffic controllers and the flight crew of Tower Air flight 69 showed that during the initial approach to runway 19R, at 0932:23, for the first attempt at landing, the flight crew reported receiving the most recent Automatic Terminal Information Service (ATIS) information, GOLF. The approach controller also reported that the runway visual range in the touchdown zone of runway 19R was 700 meters. The approach chart for the Category I ILS approach to runway 19R requires a minimum visibility of 550 meters. At 0941:45, the flight was told to contact the control tower. At 0943:25, the local controller cleared the flight to land. At 0945:19, the flight crew reported to the local controller that they were performing a go-around. The flight was then instructed to contact the approach controller.

At 0946:04, the flight crew contacted the approach controller and requested another approach. At 0952:17, the approach controller informed the crew that the touch zone visual range was now 450 meters. At 0954:40, the flight was cleared for another approach. At 0955:43, the approach controller reported that the touchdown zone visual range was now 600 meters. The flight was then instructed to contact the control tower. At 0956:52, the flight was cleared to land. At 0959:31, the flight is told to turn left off the runway and contact the ground controller. See attached ATC transcripts.

Recorded radar data from the Schiphol ATC Approach Control, showed that Tower Air 069 flew a normal approach to runway 19R. At about 09:44:41, the flight crossed over the approach end of runway 19R. At 09:44:53, the flight was over the runway and starting to veer to the right. At 09:45:17, the aircraft was off to the right side of the runway and starting to climb. See attached recorded radar data.

Readout of the digital flight data recorder (DFDR) showed that 1 second before main landing gear contact with the runway, as recorded by the tilt switch parameter, the control column position and pitch attitude began to increase in the nose-up direction. The main landing gear made runway contact for 2 seconds. As runway contact was made the engine thrust values began a symmetrical increase from a steady value of about 1.3 EPR. One second after main landing gear contact the radio altimeter increased to 7.8 feet, the pitch increased to 11.9 degrees nose up, and the roll increased to 13.2 degrees right wing down. Three seconds after main landing gear contact the radio altimeter passed 30 feet, the roll had increased to 24 degrees right wing down and the pitch attitude had increased to 14 degrees nose up. For the 10-second period from 1 second before main landing gear touchdown to 9 seconds after main landing gear touchdown, the aircraft's heading changed from 178 degrees to 199 degrees. The remaining data was consistent with a go-around and subsequent landing on runway 19R. See attached Flight Data Recorder Group Chairman Factual Report.

The Netherlands Aviation Safety Board has delegated the investigation and responsibility for reporting of this incident to the United States NTSB in accordance with ICAO Annex 13.

Aircraft

Registration
N616FF
Reported as
Boeing 747-212B
Category
Airplane
Serial number
21939
Airframe hours
61,448
Engine
P&W JT9D-7Q, 51,900 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Tower Air, Inc.
Registered owner
First Security Bank Of Utah
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · November 16, 1995 · 245 hours before
Departed
VABB · Bombay, OF
Destination
EHAM
Flight plan
IFR
Airport
EHAM · Schiphol, runway 19R, 10,827 × 148 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
44
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
12,400 total · 8,800 in this make and model · 6,000 as pilot in command · 244 in the last 90 days · 87 in the last 30 days · 9 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
130° at 5 knots
Lowest ceiling
200 ft overcast
Temperature
28 °F, dew point 28 °F
Altimeter
30.00 inHg
Observed at
EHA, 1 nm away