NYC06FA128

NTSB accident investigation · Embraer EMB-170 · Dulles, VA · May 31, 2006

Accident · Serious injuriesField investigationFinal report
Date
May 30, 2006, 20:43 local (May 31, 2006, 00:43 UTC)
Place
Dulles, VA
Injuries
1 serious, 60 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N651RWEmbraer EMB-170
Weather
Visual (VMC) · Day
Status
Completed · report March 31, 2008
Report
Approved by Office Director
Parties
FAA/FSDO, Shuttle America, Embraer Aircraft
FAA report
20060530010479A
Case key
63799

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

Improper servicing of the nose landing gear strut and the operator's inadequate maintenance procedure. A factor was the inadequate checklist provided to the flight crew by the operator.

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
Checklist - inadequateCompany/operator managementFactor
Fluid,hydraulic - inadequate
Maintenance,service of aircraft/equipment - improperCompany maintenance personnelCause
Landing gear,main gear strut - improperly servicedCause

Analysis

After departure, the first officer was unable to raise the landing gear handle to retract the landing gear. The flight crew discussed the situation and did not believe they had a landing gear malfunction, as they did not receive an Engine Indicating and Crew Alerting System (EICAS) message. They decided to press the "Downlock Release" button to raise the gear, the landing gear subsequently retracted, and the flight continued to the destination airport area uneventfully. As the flight crew attempted to extend the landing gear for landing, the nose landing gear (NLG) did not extend. They prepared for an emergency landing, and touched down "normally" on the main landing gear. The airplane came to rest on the runway, and during the evacuation, one passenger was seriously injured. Three days prior to the accident, the airplane had its NLG strut serviced as part of its approved maintenance program. The following day, a pilot reported that the NLG was "low" and "sounded like it was bottoming out." The NLG strut was checked by maintenance personnel, and found to be within limits. Additionally, during the day prior to the accident, a pilot reported that the landing gear did not retract after takeoff. Maintenance personnel believed the problem to be the landing gear control lever, and replaced it. Examination of the NLG, after the accident, revealed the NLG fluid volume was approximately two-fifths of what a normally serviced NLG should contain. Disassembly of the NLG revealed evidence of "bottoming," or under-service operation. A review of the operator's maintenance job card titled "Servicing NLG Shock Strut," revealed discrepancies when compared to the manufacturers Aircraft Maintenance Manual (AMM). The operator's maintenance job card did not contain a procedure to fill the shock strut with the final volume of hydraulic fluid. The accident airplane was equipped with Proximity Sensor Electronics Modules (PSEMs), which relayed the position of the landing gear to the EICAS. The model of PSEM, which was installed on the airplane, was not the most current model, and by design, would not generate an EICAS message ("LG WOW SYS FAIL") if the nose gear did not retract or extend. Examination of the operator's "Gear Lever Cannot Be Moved Up" checklist revealed discrepancies when compared to the airplane manufacturer's checklist. The operator's checklist began with the condition: "LG WOW SYS FAIL message displayed," and the manufacturer's checklist did not. Since the crew did not receive a "LG WOW SYS FAIL" message, they did not have clear written guidance on what action to take when the landing gear handle could not be moved to the retracted position.

Factual narrative

History of flight

On May 30, 2006, at 2043 eastern daylight time, an Embraer EMB-170, N651RW, operated by Shuttle America Corp., as United Express flight 7512, was substantially damaged while landing at the Washington Dulles International Airport (IAD), Dulles, Virginia. The certificated airline transport pilot, certificated commercial pilot, 2 flight attendants, and 56 passengers were not injured. One passenger sustained a serious injury. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight that originated at George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The scheduled passenger flight was conducted under 14 Code of Federal Regulations Part 121.

According to the flight crew, during initial climbout from IAH, the first officer was unable to raise the landing gear handle to retract the landing gear. The flight crew discussed the situation and did not believe that there was a landing gear malfunction, as they did not observe an Engine Indicating and Crew Alerting System (EICAS) message. The flight crew was unsure which checklist to use in the Quick Reference Handbook (QRH), since the "Gear Lever Cannot Be Moved Up" checklist began with the condition: "LG WOW SYS FAIL message displayed." As they discussed the situation further, they decided that since there was no EICAS message displayed, there was no landing gear problem and the issue must have been with the down-lock. They thought there was no up-lock in the landing gear system, and they would be able to extend the landing gear again. They decided to press the "Downlock Release" button to raise the gear, the landing gear subsequently retracted, and the flight continued to the Dulles area uneventfully.

The flight crew was cleared for a visual approach to runway 19R at IAD, and when the airplane was on the base leg of the traffic pattern, the flight crew performed the "Landing Checklist." While attempting to extend the landing gear, the flight crew received a "LG LEVER DISAG" message on the EICAS, and subsequently initiated a missed approach to troubleshoot the landing gear problem.

The flight crew performed the "Landing Gear Lever Disagree" checklist, which prompted them to the "Abnormal Landing Gear Extension Checklist." They cycled the landing gear several times, during which the cockpit indications were "normal" when the landing gear was retracted, and when the gear was extended, the cockpit indications showed that the main landing gear were extended but the nose landing gear was not.

The flight crew decided to return to the airport, and entered the traffic pattern for a low approach to runway 19L for control tower personnel to visually confirm the landing gear position. Tower personnel reported that the main landing gear were down, and the nose gear doors were open; however, the nose landing gear remained in the wheel well.

The flight crew continued in the traffic pattern while they briefed the flight attendants and passengers of the landing gear problem, and instructed them to prepare for an emergency landing. The flight crew flew an extended traffic pattern for runway 19L, and touched down "normally" on the main landing gear. The Captain held the nose of the airplane up until the airplane "lost elevator effectiveness," and then the nose slowly settled to the runway.

After the airplane came to a stop on the runway, the crew initiated an emergency evacuation using the rear door (2L and 2R) evacuation slides. During the evacuation, one passenger sustained a broken ankle.

Personnel information

According to information provided by the operator, the captain held an airline transport pilot certificate, with a rating for airplane multiengine land. The captain reported approximately 6,600 total hours of flight experience, 700 of which were in make and model.

The first officer held a commercial pilot certificate with a rating for airplane multiengine land. The first officer reported approximately 2,800 total hours of flight experience, 1,000 hours of which were in make and model.

Aircraft information

According to company records, the accident airplane was manufactured in 2005, and delivered from Embraer to Shuttle America Corp. in May 2005. At the time of the accident, the airplane had accumulated 2,517 total hours of flight time.

On May 27, 2006, the airplane's nose landing gear (NLG) strut was serviced as part of an approved maintenance program. At the time of the servicing, the airplane had accumulated 2,499 hours of operation.

A review of the airplane's maintenance records revealed the following entries during the days preceding the accident:

1) May 28, 2006:

a. Pilot write-up: "Nose strut low, sounds like bottoms out during taxi."

b. Corrective action: "Upon inspection of NLG, found strut extension to be in limits with NLG servicing chart IAW EMB 170 AMM."

2) May 29, 2006:

a. Pilot write-up: "Landing gear did not retract after takeoff. Handle would not move to up position."

b. Corrective action: "Trouble shoot, suspect faulty landing gear handle. Inspected aircraft, found to be safe for ferry flight with landing gear down and pin and safety from ATL to IND."

c. Maintenance write-up: "Aircraft to be ferried from ATL to IND for INOP landing gear handle. Aircraft to be flown with gear down and pin and safety."

d. Corrective action: "Removed and replaced landing gear control lever in accordance with AMM 32-33-01.OP/check good."

A review of the operator's job card, titled "Servicing NLG Shock Strut," dated October 1, 2004, revealed discrepancies when compared to the manufacturer's Aircraft Maintenance Manual (AMM), titled "Nose Landing Gear Shock Strut - Servicing," dated October 20, 2004. The operator's job card did not contain a procedure to fill the shock strut with the final volume of hydraulic fluid.

Meteorological information

Weather reported at IAD, at 2052, included wind from 150 degrees at 3 knots, 9 miles visibility, scattered clouds at 25,000 feet, temperature 28 degrees Celsius (C), dew point 20 degrees C, and altimeter setting of 30.06 inches of mercury.

Flight recorders

The cockpit voice recorder (CVR) was forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory in Washington, D.C. for analysis.

The two-hour long recording began at 1840, while the airplane was in cruise flight at flight level (FL) 310.

At 1945, after reporting on the Washington Center frequency, the flight crew began discussing the landing gear problem they encountered after departure. The captain stated, "I don't know if the gear not coming up is an emergency but pushing the downlock release would constitute an emergency if we had an EICAS message. I definitely wouldn't have done that." The first officer agreed and stated, "you got two alternate means of lowering the gear...." The first officer also stated that he didn't know enough details about the system to know all the conditions that would keep the lever from coming up.

At 2004, the airplane was cleared to land, the captain called for the landing gear to be lowered, and the first officer lowered the landing gear. Thirteen seconds later, two electronic tones were audible and the first officer stated, "what's up with the gear?" About thirteen seconds after that, the captain called for a go-around and informed the tower of their intentions.

Over the following 15 minutes, the flight crew continued to troubleshoot the landing gear system and performed the abnormal landing gear extension checklist and the partial gear up landing checklist. They declared an emergency and requested a "flyby" for the tower personnel to inspect the landing gear.

During the "flyby" to runway 19L, tower personnel reported to the flight crew that the nose gear door was open but the gear was not down.

The crew then reentered the traffic pattern for runway 19R, and performed a landing on the

Aircraft

Registration
N651RW
Reported as
Embraer EMB-170
Category
Airplane
Serial number
17000072
Engine
General Electric CF34-8E, 14,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Shuttle America Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · May 1, 2006
Departed
IAH · Houston, TX
Destination
IAD · Dulles, VA
Flight plan
IFR
Airport
IAD · Dulles International Airport, runway 19L, 11,500 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
29
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 1, 2006
Seat
Left
Flight hours
6,600 total · 700 in this make and model
Role
Co-pilot
Age
29
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 1, 2005
Seat
Right
Flight hours
2,800 total · 1,000 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 3 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 68 °F
Altimeter
30.05 inHg
Observed at
IAD

FAA reports on this event · 1

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