WPR10IA430

NTSB incident investigation · Airbus A320-232 · Sacramento, CA · August 26, 2010

Incident · Minor injuriesIncident investigationFinal report
Date
August 26, 2010, 12:51 local (19:51 UTC)
Place
Sacramento, CA
Injuries
7 minor, 84 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N590JBAirbus A320-232
Defining event
Approach: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report March 7, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, JetBlue Airways
FAA report
20100826047369I
Case key
77100

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 first officer’s inadvertent activation of the parking brake in flight, which led to the airplane abruptly stopping and all four of its main landing gear tires deflating, and his use of a nonstandard procedure to cancel the airplane's monitoring alert system.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: use of policy/procedurePersonnel issues › Task performance · CopilotAirbus A320-232: 1 caseAll aircraft: 191 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · CopilotAirbus A320-232: 1 caseAll aircraft: 397 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Upon touchdown and with the first officer as the pilot flying, the airplane rapidly decelerated. After touchdown, air traffic control tower personnel notified the flight crew that smoke and sparks were coming from the airplane's main landing gear. The captain took control of the airplane and maintained directional control as it abruptly came to stop about 2,000 feet from the touchdown point. Postaccident examination of the airplane revealed that all four main landing gear tires were deflated and showed evidence of being locked on touchdown and that the main wheel rims were ground down. According to recorded digital flight data, the parking brake engaged about 5,116 mean sea level and remained engaged throughout the remainder of the flight and landing roll. The data also indicated that the speed brake was activated about 4 seconds before the parking brake. The speed brake lever is on the left side of the center console near the parking brake switch, which is at the bottom center of the console. The first officer stated that he activated the speed brake. It is likely that the first officer inadvertently activated the parking brake at the same time. The flight crew stated that they were unaware of any indications or warnings related to the parking brake system during flight. The airplane's Electronic Centralized Aircraft Monitoring (ECAM) system should alert the flight crew when the parking brake is engaged in flight. However, after the accident, the first officer stated that he selected and held down the ECAM emergency cancel pushbutton for several seconds and that this was his typical procedure to preempt the autopilot disconnect audio. This action also terminated, in part, most of the visual alert indications associated with the in-flight parking brake activation. (The alerts would appear in the cancelled caution field on the status page and could be recalled, if necessary.) The operator's procedures state to only use the ECAM emergency cancel pushbutton to suppress spurious master cautions. A review of the airplane's cockpit voice recorder transcript revealed no audible autopilot disconnect or parking brake activation warnings. Examination of the airplane's parking brake and ECAM revealed no mechanical malfunctions or failures that would have precluded normal operation. If the first officer had not cancelled out most of the visual alert indications associated with the in-flight parking brake activation, it is likely that a visual warning would have alerted the flight crew to the in-flight parking brake activation.

Factual narrative

On August 26, 2010, about 1251 Pacific daylight time, an Airbus 320-232, N590JB, experienced an abnormal landing at the Sacramento International Airport (SMF), Sacramento, California. During touchdown and landing rollout on runway 16R, the airplane rapidly decelerated; the main landing gear tires blew out, and a minor tire-related fire erupted. All of the airplane's occupants, emergency evacuated by use of the cabin door slides. The airplane sustained minor damage. The two airline transport pilots, three flight attendants and 79 passengers were not injured. Seven passengers received minor injuries during the evacuation process. The airplane was registered to and operated by JetBlue Airways as flight number 262, under the provisions of Title 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The scheduled domestic passenger flight originated about 1141 from the Long Beach Airport, Long Beach, California.According to the flight crew, the flight and approach to runway 16R were normal. The first officer was the pilot flying. Upon touchdown, the airplane began a rapid deceleration, and the first officer remarked to the captain that it felt like a main landing gear tire blew out. About this time, air traffic control tower personnel reported observing sparks and smoke in the area of the main landing gear. The captain took control of the airplane and maintained directional control as the airplane came to a stop about 2,000 feet from its touchdown point. The captain directed the first officer to initiate the Quick Reference Checklist (QRC) for ground evacuation, up to the evacuation decision point. At that time, air traffic control tower personnel confirmed smoke and fire were still visible around the main landing gear. Based on this information the captain elected to evacuate the airplane. Crash fire rescue personnel and equipment responded to the airplane, which was stopped on the runway. According to the flight crew and flight attendants, a swift and orderly evacuation was performed via emergency evacuation slides at both the forward main cabin doors and the rear left door. The rear right door was not used since a flight attendant observed smoke in the vicinity. The airplane was subsequently examined by the operator and Federal Aviation Administration (FAA) personnel. Airplane damage was limited to four deflated main landing gear tires and the wheel rims were ground down. The main landing gear tires showed evidence of being locked on touchdown. Ground damage was limited to minor grazing of the runway's surface. The airplane's Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR) were removed for analysis. The DFDR was examined by the operator and the National Transportation Safety Board (NTSB). According to the airplane's recorded flight data, the parking brake had become engaged in flight during the landing approach at approximately 5,116 feet meansea level, and remained engaged throughout the remainder of the flight and landing roll. The parking brake activation occurred about the same time the autopilot was disconnected. The downloaded data indicated that the airplane was being configured with speed brakes about 4 seconds prior to the parking brake activation. The first officer stated that he activated the speed brakes. The airplane controls for the speed brake and parking brake are located in the center console in the near vicinity of each other. The speed brake lever is on the left side of the console and is activated by pulling the lever. The parking brake switch is on the bottom center of the console and is activated by pulling and rotating the switch. The CVR was examined by the NTSB Vehicle Recorder Division. The airplane's CVR revealed no sounds of the associated warning audio for the parking brake activation or autopilot disconnect. The CVR did reveal sounds captured around the time of the parking activation, however, the source of the sounds proved to be inconclusive. Non-essential communication existed during the sterile cockpit portion of the descent and approach. During interviews with the flight crew, neither pilot recalled any abnormal indications or cockpit warnings associated with the parking brake system prior to landing. The Electronic Centralized Aircraft Monitoring (ECAM) system is designed to monitor and advise the flight crew of the airplane's status. According to the manufacturer, if the parking brake is engaged in flight, the ECAM illuminates the master caution light, a single chime audio associated with the master caution light is given after a 3 second delay, and a parking brake on advisory message is presented. At 800 feet above ground level (agl), the alerts associated with the parking brake selected on in flight, are reactivated by the ECAM, in the event the alert or master caution was cleared by the flight crew. The applicable hydraulic system also provides an indication that the parking brake was activated in flight by the braking pressure indicators becoming operational. However, normal checklists do not require an in flight check of the brake pressure indicators. The operator performed an examination and functional test of the airplane's parking brake system and central warning systems in accordance with the manufacturer's maintenance manual, with no abnormalities noted. The parking brake control switch was also functionally checked by the operator with no abnormalities noted. A vendor conducted an examination and breakdown of the parking brake control valve and control switch with no abnormalities noted. On a follow up interview, the first officer described his personal technique where he would preempt the autopilot disconnect audio by selecting the ECAM emergency cancel pushbutton prior to disconnecting the autopilot and would hold it for several seconds afterwards. The autopilot disconnect warning audio (cavalry charge) is temporary and last a maximumof 1.5 seconds, if the autopilot is disengaged using standard procedures. Selection of the ECAM emergency cancel pushbutton would terminate the autopilot disconnect audio and any other present caution (master caution lights, ECAM alert message) for the rest of the flight. The alert would appear in the cancelled caution field on the status page and could be recalled if necessary. The operator's procedure has a note to use the ECAM emergency cancel pushbutton only for spurious master cautions. According to the manufacturer, if the ECAM emergency cancel pushbutton is selected prior to the parking brake on alert being displayed; the master caution light and single chime associated with the parking brake on alert would be inhibited. In addition, at 800 feet agl, the "parking brake on" alert message and master caution would not be reactivated. The ECAM emergency cancel pushbutton is not a parameter recorded by the DFDR.

Aircraft

Registration
N590JB
Reported as
Airbus A320-232
Category
Airplane
Serial number
2231
Airframe hours
25,986
Engines
IAE V2527-A5, 25,000 lbs thrust, turbo fanIAE V2500SERIES, 25,000 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Jetblue Airways Corp
Registered owner
Jetblue Airways Corp
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 26, 2010
Departed
LGB · Long Beach, CA
Destination
SMF · Sacramento, CA
Flight plan
IFR
Airport
SMF · Sacramento International, runway 16R, 8,600 × 150 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 31, 2009
Seat
Left
Flight hours
8,716 total · 4,397 in this make and model · 4,874 as pilot in command · 240 in the last 90 days · 79 in the last 30 days · 7 in the last 24 hours
Role
Co-pilot
Age
43
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 17, 2009
Seat
Right
Flight hours
9,100 total · 2,217 in this make and model · 5,264 as pilot in command · 279 in the last 90 days · 91 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 55 °F
Altimeter
29.85 inHg
Observed at
SMF

Docket · 17

The files NTSB released with the investigation on January 7, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 MB in all.

FAA reports on this event · 1

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