| Status: | Schlussbericht |
| Datum: | 30 JUL 1992 |
| Zeit: | 17:41 |
| Flugzeugtyp: | Lockheed L-1011 TriStar 1 |
| Fluggesellschaft: | Trans World Airlines - TWA |
| Kennzeichen: | N11002 |
| Werknummer: | 1014 |
| Baujahr: | 1972 |
| Betriebsstunden: | 49662 |
| Anzahl Zyklen der Zelle: | 19659 |
| Triebwerk: | 3 Rolls Royce RB211-22B |
| Besatzung: | Todesopfer: 0 / Insassen: 12 |
| Fluggäste: | Todesopfer: 0 / Insassen: 280 |
| Gesamt: | Todesopfer: 0 / Insassen: 292 |
| Sachschaden: | Zerstört |
| Konsequenzen: | Written off (damaged beyond repair) |
| Unfallort: | New York-John F. Kennedy International Airport, NY (JFK) (USA)
 |
| Flugphase: | Start (TOF) |
| Betriebsart: | Inländischer planmäßiger Passagierflug |
| Flug von: | New York-John F. Kennedy International Airport, NY (JFK/KJFK), USA |
| Flug nach: | San Francisco International Airport, CA (SFO/KSFO), USA |
| Flugnummer: | 843 |
Unfallbericht:Flight 843 to San Francisco was cleared to push back from the gat at 17:16 and was cleared to taxi to runway 13R at 17:25. Takeoff was commenced at 17:40. The VR speed was reached at 17:41:03 and the aircraft lifted off the runway. At that moment the stick shaker activated and the first officer, who was making the takeoff, sensed a loss of performance. The captain than took over control and decided to abort the takeoff. The TriStar touched down again (at a vertical descent rate of 14 feet/sec - the structural design limit being 6 feet/sec -) after being airborne for about 6 seconds. Maximum braking and reverse thrust were applied but the airplane didn't decelerate as expected. When it became apparent that he would not be able to stop before hitting the blast fence at the end of the runway, the captain turned the plane left off the runway onto a field. The TriStar came to rest 296 feet to the left of the runway and caught fire.
It appeared that the right Angle of Attack (AOA) sensor had experienced 9 previous malfunctions. The intermittent malfunction was not detectable during pre-flight system tests by the pilots and didn't trigger a fault light. This permitted the sensor to cause a false warning when the air-ground sensor on the landing gear went into the air status on takeoff.
PROBABLE CAUSE: "Design deficiencies in the stall warning system that permitted a defect to go undetected, the failure of TWA's maintenance system and inadequate crew coordination between the captain and first officer that resulted in their inappropriate response to a false stall warning."
Informationsquelle:
» FSAT 94-08
» ICAO Adrep Summary 1/95
» NTSB/AAR-93/04
Official accident investigation report
Sicherheitsempfehlungen
NTSB issued 10 Safety Recommendations
| Issued: 08-MAR-1993 | To: FAA | A-93-016 |
| REQUIRE THE INSPECTION OF WINDOWS THAT ARE INSTALLED IN EMERGENCY EXITS TO ENSURE THAT THEY ARE FREE FROM DAMAGE THAT WOULD INTERFERE WITH A CLEAR VIEW AND ORDER THE REPLACEMENT OF WINDOWS THAT ARE NOT AIRWORTHY. (Closed - Acceptable Alternate Action) |
| Issued: 08-MAR-1993 | To: FAA | A-93-017 |
| INFORM OPERATORS OF L1011 AIRPLANES OF THE NECESSITY TO ADJUST SEATBELTS TIGHTLY AND TO LOCK BOTH SIDES OF THE SEATBELTS (IF LOCKS ARE INSTALLED) THAT ARE INSTALLED ON COCKPIT OBSERVER SEATS BEFORE TAKEOFF, LANDING AND DURING TURBULENCE. (Closed - Acceptable Action) |
| Issued: 08-MAR-1993 | To: FAA | A-93-018 |
| RESEARCH THE EFFECT OF AGING UPON THE SELF-EXTINGUISHING ABILITY OF CABIN INTERIOR FURNISHINGS AND TEST FURNISHINGS THAT WERE CERTIFIED TO 14 CFR 25.853(A)(1)(I) TO DETERMINE IF THEY COMPLY WITH THE SELF-EXTINGUISHING REQUIREMENTS. INTERIOR FURNISHINGS THAT FAIL TO COMPLY WITH 14 CFR 25.853(A)(1)(I) SHOULD BE IMMEDIATELY REPLACED WITH MATERIALS THAT COMPLY WITH 14 CFR 25-853, APPENDIX F. (Closed - Acceptable Action) |
| Issued: 28-MAY-1993 | To: FAA | A-93-049 |
| ISSUE AN AIR CARRIER OPERATIONS BULLETIN DIRECTING PRINCIPAL OPERATIONS INSPECTORS FOR 14 CFR 121 AND 14 CFR 135 AIRLINES TO INCLUDE IN THE TRAINING AND PROCEDURES A REQUIREMENT FOR CREW COORDINATION BRIEFINGS ON ACTIONS TO TAKE IN THE EVENT OF ABNORMAL SITUATIONS DURING THE TAKEOFF AND INITIAL CLIMB PHASE OF FLIGHT, AND THE PROPER TECHNIQUES FOR THE TRANSFER OF CONTROL OF THE AIRPLANE, ESPECIALLY DURING TIME-CRITICAL PHASES OF FLIGHT. (Closed - Acceptable Action) |
| Issued: 28-MAY-1993 | To: FAA | A-93-050 |
| ISSUE AN AIR CARRIER MAINTENANCE BULLETIN DIRECTING THE PRINCIPAL MAINTENANCE AND AVIONICS INSPECTORS FOR 14 CFR 121 AND 14 CFR 135 AIRLINES TO REVIEW THE AIRLINES\' MAINTENANCE AND QUALITY ASSURANCE PROGRAMS AND TAKE APPROPRIATE ACTIONS TO VERIFY THAT THE TREND MONITORING PROGRAMS ARE STRUCTURED TO DETECT REPETITIVE MALFUNCTIONS BY MEANS OF FLIGHT-HOUR MONITORING, AS WELL AS CALENDAR-DAY MONITORING. (Closed - Acceptable Action) |
| Issued: 28-MAY-1993 | To: FAA | A-93-051 |
| ISSUE AN AIRWORTHINESS DIRECTIVE TO REQUIRE THAT A CAUTION OR WARNING LIGHT ILLUMINATES ON THE PILOTS\' CAUTION-WARNING PANEL IN THE EVENT OF A FAILURE WITHIN THE CIRCUITRY OF L-1011 STALL WARNING SYSTEMS DURING GROUND OR FLIGHT OPERATIONS. (Closed - Unacceptable Action) |
| Issued: 28-MAY-1993 | To: FAA | A-93-052 |
| REQUIRE THAT THE REDUNDANT STALL WARNING SYSTEMS INSTALLED ON TRANSPORT-CATEGORY AIRPLANES HAVE GROUND TEST FEATURES AND SELF-MONITORING SYSTEMS TO ALERT THE PILOTS TO MALFUNCTIONS IN THE STALL WARNING SYSTEMS. (Closed - Acceptable Action) |
| Issued: 28-MAY-1993 | To: FAA | A-93-053 |
| ISSUE AIR CARRIER BULLETINS DIRECTING THE PRINCIPAL INSPECTORS FOR 14 CFR 121 AND 14 CFR 135 AIRLINES TO REVIEW THE CIRCUMSTANCES OF THE ACCIDENT INVOLVING TWA FLIGHT 843 ON JULY 30, 1992, AND TO MAKE THE FACTS, CONDITIONS, AND CIRCUMSTANCES OF THE ACCIDENT KNOWN TO THE APPROPRIATE AIRLINE OPERATIONS, TRAINING, AND MAINTENANCE PERSONNEL. (Closed - Acceptable Action) |
| Issued: 28-MAY-1993 | To: FAA | A-93-054 |
| CONDUCT A HUMAN FACTORS STUDY, IN COOPERATION WITH THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION, OF THE PRACTICE BY MANY AIRLINES OF REQUIRING THE CAPTAIN TO INITIATE AND EXECUTE A REJECTED TAKEOFF, EVEN WHEN THE FIRST OFFICER IS MAKING THE TAKEOFF. THE STUDY SHOULD INCLUDE A THOROUGH EXAMINATION OF THE PRACTICE OF HAVING THE CAPTAIN KEEP HIS HAND ON THE POWER LEVERS WHEN THE FIRST OFFICER IS MAKING THE TAKEOFF. THE STUDY SHOULD ALSO INCLUDE A COMPREHENSIVE REVIEW AND ANALYSIS OF ACCIDENT AND INCIDENT DATA AND SIMULATOR OR OTHER RESEARCH, AS NECESSARY. THE RESULTS OF THE STUDY SHOULD BE WIDELY DISSEMINATED TO THE AIRLINE INDUSTRY FOR USE IN EVALUATING AND REVISING, IF APPROPRIATE, REJECTED TAKEOFF PROCEDURES AND TRAINING. (Closed - Acceptable Action) |
| Issued: 28-MAY-1993 | To: PORT AUTHORITY OF NEW YORK AND NEW JERSEY | A-93-069 |
| REMOVE THE BLAST FENCE LOCATED NEAR THE APPROACH END OF RUNWAY 31L AT JOHN F. KENNEDY INTERNATIONAL AIRPORT, AND IMPLEMENT ALTERNATIVE METHODS TO PROTECT AIRPLANE OPERATIONS FROM JET BLAST ON RUNWAY 4R/22L. (Closed - Acceptable Action) |
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Fotos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from New York-John F. Kennedy International Airport, NY to San Francisco International Airport, CA as the crow flies is 4123 km (2577 miles).
