MIA96LA108

NTSB accident investigation · Boeing 737-200 · Jacksonville, FL · March 21, 1996

Accident · No injuriesLimited investigationFinal report
Date
March 20, 1996, 19:51 local (Mar 21, 1996, 00:51 UTC)
Place
Jacksonville, FL
Injuries
62 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
EICLKBoeing 737-200
Weather
Visual (VMC) · Night/dark
Status
Completed · report October 22, 1996
Report
Approved by Office Director
Case key
38000

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

failure of the nose gear taxi light support bracket due to in service damage, which resulted in debris being ingested by the engines. Contributing to the accident was the failure of company maintenance personnel to comply with a Grimes Service Bulletin and a Boeing Service Letter which recommended changing the nose gear taxi light support bracket to an improved design.

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 - initial climb
Landing light(s) - crackedCause
Landing light(s) - separationCause
Maintenance,service bulletin/letter - not complied withCompany maintenance personnelCause
Loss of engine power(partial) - nonmechanicalTakeoff - initial climb
Compressor assembly,forward fan - foreign object damageCause

Analysis

During takeoff the nose gear taxi light separated from the nose landing gear when the aluminum support bracket failed. The debris from the nose gear taxi light was ingested by both engines causing damage to the fan sections. The nose gear taxi light assembly is manufactured by Grimes Aerospace Company. In June 1992 Grimes began offering a stainless steel support bracket to replace the aluminum support bracket. In service history showed that the aluminum support bracket was cracking due to damage from the nose gear tow bar during towing operations. The stainless steel bracket is resistant to this damage. The change to the new stainless steel bracket was the subject of Grimes Service Bulletins in 1992 and 1993, and a Boeing Service Letter in 1994.

Factual narrative

On March 20, 1996, about 1951 eastern standard time, a Boeing 737-200, Irish registration EI-CLK, operated by Air South Airlines, Inc., as flight 904, a 14 CFR Part 121 scheduled domestic passenger flight, from Miami, Florida, to Atlanta, Georgia, with a scheduled stop in Jacksonville, Florida, sustained separation of the nose gear taxi light and resultant foreign object damage to both engines during takeoff from Jacksonville. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft sustained substantial damage and the airline transport-rated pilot, first officer, 3 flight attendants, and 57 passengers were not injured. The flight was departing Jacksonville at the time of the accident.

The captain stated that during rotation they observed sparks coming from the left side of the aircraft. All engine instruments showed normal readings. They returned to Jacksonville and landed without incident. Postaccident examination showed the nose gear taxi light support bracket had failed and the nose gear taxi light assembly had separated from the aircraft. A portion of the support bracket remained attached to the nose landing gear. The compressor sections of both engines had sustained foreign object damage.

The nose gear taxi light assembly installed on all Boeing 737 series aircraft is made by Grimes Aerospace Company. On June 1, 1992, Grimes issued Service Bulletin 50-0199-33-0004, which describes a modification to replace the aluminum support bracket with a steel bracket on the nose gear taxi light assembly of newer Boeing 737 series aircraft. On November 30, 1993, Grimes issued Service Bulletin 50-0128-33-005, which requires installation of the steel bracket on the nose gear taxi light assembly of older Boeing 737 series aircraft. On December 19, 1994, Boeing Commercial Airplane Group issued Service Letter 737-SL-33-016-A, which recommended that all operators of Boeing 737 series aircraft comply with the above referenced Grimes Service Bulletins. See attached Grimes Service Bulletins and Boeing Service Letter.

Service history showed the aluminum bracket was subject to damage from the nose gear tow bar during towing operations. The improved stainless steel bracket is resistant to damage from towing operations. Examination of the portion of the nose gear taxi light bracket which remained attached to the nose landing gear, showed it was made from aluminum.

Aircraft

Registration
EICLK
Reported as
Boeing 737-200
Category
Airplane
Serial number
21733
Airframe hours
35,690
Engine
P&W JT8D-15, 15,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Air South Airlines, Inc.
Registered owner
Gecas
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 20, 1996 · 6 hours before
Departed
JAX
Destination
ATL · Atlanta, GA
Flight plan
IFR
Airport
JAX · Jacksonville Intl, runway 25, 8,000 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
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
10,000 total · 1,000 in this make and model · 7,500 as pilot in command · 150 in the last 90 days · 63 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
310° at 16 knots, gusting 27
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 25 °F
Altimeter
29.00 inHg
Observed at
JAX, 1 nm away