The Alaska 261
 Crash Findings

NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of
December 10, 2002
(Information subject to editing)

Abstract of Aviation Accident Report
Alaska Airlines Flight 261, MD-83, N963AS
Pacific Ocean about 2.7 Miles North of Anacapa Island, California
January 31, 2000
NTSB/AAR-02/01

This is a synopsis from the report of an aviation accident and does not include the Board's rationale for the probable cause, conclusions, or safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached safety recommendations have been extracted. The pertinent safety recommendation letters will be distributed to the recommendation recipient as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

On January 31, 2000, about 1621 Pacific standard time, Alaska Airlines, Inc., flight 261, a McDonnell Douglas MD-83, N963AS, crashed into the Pacific Ocean about 2.7 miles north of Anacapa Island, California. The 2 pilots, 3 cabin crewmembers, and 83 passengers on board were killed, and the airplane was destroyed by impact forces. Flight 261 was operating as a scheduled international passenger flight under the provisions of 14 Code of Federal Regulations Part 121 from Lic Gustavo Diaz Ordaz International Airport, Puerto Vallarta, Mexico, to Seattle-Tacoma International Airport, Seattle, Washington, with an intermediate stop planned at San Francisco International Airport, San Francisco, California. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

CONCLUSIONS

1. The flight crewmembers on Alaska Airlines flight 261 were properly certificated and qualified and had received the training and off-duty time prescribed by Federal regulations. No evidence indicated any preexisting medical or other condition that might have adversely affected the flight crew's performance during the accident flight.

2. The airplane was dispatched in accordance with Federal Aviation Administration regulations and approved Alaska Airlines procedures. The weight and balance of the airplane were within limits for dispatch, takeoff, climb, and cruise.

3. Weather was not a factor in the accident.

4. There was no evidence of a fire or of impact with birds or any other foreign object.

5. No evidence indicated that the airplane experienced any pre-impact structural or system failures, other than those associated with the longitudinal trim control system, the horizontal stabilizer, and its surrounding structure.

6. Both engines were operating normally before the final dive.

7. Air traffic control personnel involved with the accident flight were properly certificated and qualified for their assigned duty stations.

8. The longitudinal trim control system on the accident airplane was functioning normally during the initial phase of the accident flight.

9. The horizontal stabilizer stopped responding to autopilot and pilot commands after the airplane passed through 23,400 feet. The pilots recognized that the longitudinal trim control system was jammed, but neither they nor the Alaska Airlines maintenance personnel could determine the cause of the jam.

10. The worn threads inside the horizontal stabilizer acme nut were incrementally sheared off by the acme screw and were completely sheared off during the accident flight. As the airplane passed through 23,400 feet, the acme screw and nut jammed, preventing further movement of the horizontal stabilizer until the initial dive.

11. The accident airplane's initial dive from 31,050 feet began when the jam between the acme screw and nut was overcome as a result of operation of the primary trim motor. Release of the jam allowed the acme screw to pull up through the acme nut, causing the horizontal stabilizer leading edge to move upward, thus causing the airplane to pitch rapidly downward.

12. The acme screw did not completely separate from the acme nut during the initial dive because the screw's lower mechanical stop was restrained by the lower surface of the acme nut until just before the second and final dive about 10 minutes later.

13. The cause of the final dive was the low-cycle fatigue fracture of the torque tube, followed by the failure of the vertical stabilizer tip fairing brackets, which allowed the horizontal stabilizer leading edge to move upward significantly beyond what is permitted by a normally operating jackscrew assembly. The resulting upward movement of the horizontal stabilizer leading edge created an excessive upward aerodynamic tail load, which caused an uncontrollable downward pitching of the airplane from which recovery was not possible.

14. In light of the absence of a checklist requirement to land as soon as possible and the circumstances confronting the flight crew, the flight crew's decision not to return to Lic Gustavo Diaz Ordaz International Airport, Puerto Vallarta, Mexico, immediately after recognizing the horizontal stabilizer trim system malfunction was understandable.

15. The flight crew's decision to divert the flight to Los Angeles International Airport, Los Angeles, California, rather than continue to San Francisco International Airport, San Francisco, California, as originally planned was prudent and appropriate.

16. The flight crew's use of the autopilot while the horizontal stabilizer was jammed was not appropriate.

17. The captain should have kept the slats and flaps extended when the airplane was found to be controllable in that configuration after the initial dive. (TO BE REVISED)

18. Without clearer guidance to flight crews regarding which actions are appropriate and which are inappropriate in the event of an inoperative or malfunctioning flight control system, pilots may experiment with improvised troubleshooting measures that could inadvertently worsen the condition of a controllable airplane.

19. The acme nut threads on the accident airplane's horizontal stabilizer jackscrew assembly wore at an excessive rate.

20. Alaska Airlines' use of Aeroshell 33 for lubrication of the jackscrew assembly, acme screw thread surface finish, foreign debris, and abnormal loading of the acme nut threads were not factors in the excessive wear of the accident acme nut threads.

21. There was no effective lubrication on the acme screw and nut interface at the time of the Alaska Airlines flight 261 accident.

22. The excessive and accelerated wear of the accident jackscrew assembly acme nut threads was the result of insufficient lubrication, which was directly causal to the Alaska Airlines flight 261 accident.

23. Alaska Airlines' extension of its lubrication interval for its McDonnell Douglas MD-80 horizontal stabilizer components, and the FAA's approval of that extension, the last of which was based on Boeing's extension of the recommended lubrication interval increased the likelihood that a missed or inadequate lubrication would result in excessive wear of jackscrew assembly acme nut threads and, therefore, was a direct cause of the excessive wear and contributed to the Alaska Airlines flight 261 accident.

24. When lubricating the jackscrew assembly, removal of used grease from the acme screw before application of fresh grease will increase the effectiveness of the lubrication.

25. A larger access panel would facilitate the proper accomplishment of the jackscrew assembly lubrication task.

26. If the jackscrew assembly lubrication procedure was a required inspection item for which an inspector's signoff is needed, the potential for unperformed or improperly performed lubrications would be reduced.

27. Alaska Airlines' extension of the end play check interval, and FAA's approval of the extension, allowed the accident acme nut threads to wear to failure without the opportunity for detection and, therefore, was a direct cause of the excessive wear and contributed to the Alaska Airlines flight 261 accident.

28. Alaska Airlines' end play check interval extension should have been, but was not, supported by adequate technical data to demonstrate that the extension would not present a potential hazard.

29. The existing process by which manufacturers revise recommended maintenance task intervals and by which airlines establish and revise these intervals does not include task-by-task engineering analysis and justification and, therefore, allows for the possibility of inappropriate interval extensions for potentially critical maintenance tasks.

30. Because of the possibility that higher-than-expected wear could cause excessive wear in less than 2,000 flight hours and the additional possibility that an end play check could be unperformed or improperly performed, the current 2,000-flight-hour end play check interval specified in Airworthiness Directive 2000-15-15 may be inadequate to ensure the safety of the Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 fleet.

31. The continued collection and analysis of end play data are critical to monitoring acme nut thread wear and identifying excessive or unexpected wear rates, trends, or anomalies.

32. Until August 2000, Alaska Airlines used a fabricated restraining fixture that did not meet Boeing specifications; however, the Safety Board could not determine whether the use of this noncompliant fixture generated an inaccurate end play measurement during the last end play check or whether the use of this fixture contributed to the accident.

33. The on-wing end play check procedure, as currently practiced, has not been validated and has low reliability.

34. Deficiencies in the overhaul process increase the likelihood that jackscrew assemblies may be improperly overhauled.

35. The absence of a requirement to record or inform customers of the end play measurement of an overhauled jackscrew assembly could result in an operator unknowingly returning a jackscrew assembly to service with a higher-than-expected end play measurement.

36. Operators will maximize the usefulness of end play measurements and wear rate calculations by recording on-wing end play measurements whenever a jackscrew assembly is replaced on an airplane.

37. Because the jackscrew assembly is an integral and essential part of the horizontal stabilizer trim system, a critical flight system, it is important to ensure that maintenance facilities authorized to overhaul these assemblies possess the proper qualifications, equipment and documentation.

38. The dual-thread design of the acme screw and nut does not provide redundancy with regard to wear.

39. The design of the Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 horizontal stabilizer jackscrew assembly did not account for the loss of the acme nut threads as a catastrophic single-point failure mode. The absence of a fail-safe mechanism to prevent the catastrophic effects of total acme nut thread loss contributed to the Alaska Airlines flight 261 accident.

40. When a failure could have catastrophic results, it is not appropriate to rely on maintenance and inspection intervention to prevent the failure from occurring if a practicable design alternative could eliminate the catastrophic effects of the failure mode. (TO BE REVISED)

41. Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 series airplanes, and if found necessary other transport category airplanes, should be modified to ensure that loss of the horizontal stabilizer trim system's jackscrew assembly acme nut threads or other control assembly does not preclude continued safe flight and landing.

42. Catastrophic single-point failure modes should be prohibited in the design of all future airplanes with horizontal stabilizer trim systems, regardless of whether any element of that system is considered structure rather than system or is otherwise considered exempt from certification standards for systems.

43. The certification requirements applicable to transport-category airplanes should fully consider and address the consequences of failures resulting from wear.

44. At the time of the flight 261 accident, Alaska Airlines' maintenance program had widespread systemic deficiencies.

45. The FAA did not fulfill its responsibility to properly oversee the maintenance operations at Alaska Airlines, and at the time of the Alaska Airlines flight 261 accident, Federal Aviation Administration surveillance of Alaska Airlines had been deficient for at least several years.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of this accident was a loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly's acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines' insufficient lubrication of the jackscrew assembly.

Contributing to the accident was

(1) Alaska Airlines' extended lubrication interval, and the FAA's approval of that extension, which increased the likelihood that an unperformed or inadequate lubrication would result in excessive wear of the acme nut threads; and

(2) Alaska Airlines' extended end play check interval, and the FAA's approval of that extension, which allowed the excessive wear of the acme nut threads to progress to failure without the opportunity for detection.

(3) Contributing also to the accident was the absence on the MD-80 of a fail-safe mechanism to prevent the catastrophic effects of total acme nut thread loss.

SAFETY RECOMMENDATIONS

As a result of the investigation of the Alaska Airlines flight 261 accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

1. Issue a flight standards information bulletin directing air carriers to instruct pilots that in the event of an inoperative or malfunctioning flight control system, if the airplane is controllable they should complete only the applicable checklist procedures and should not attempt any corrective actions beyond those specified. In particular, in the event of an inoperative or malfunctioning horizontal stabilizer trim control system, after a final determination has been made in accordance with the applicable checklist that both the primary and alternate trim systems are inoperative, neither the primary nor the alternate trim motor should be activated, either by engaging the autopilot or using any other trim control switch or handle. Pilots should further be instructed that if checklist procedures are not effective, they should land at the nearest suitable airport. (A-02-XX)

2. As part of the response to Safety Recommendation A-01-41, require operators of Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 series airplanes to remove degraded grease from the jackscrew assembly acme screw and flush degraded grease and particulates from the acme nut before applying fresh grease. (A-02-XX)

3. As part of the response to Safety Recommendation A-01-41, require operators of Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 series airplanes, in coordination with Boeing, to increase the size of the access panels that are used to accomplish the jackscrew assembly lubrication procedure. (A-02-XX)

4. Establish the jackscrew assembly lubrication procedure as a required inspection item that must have an inspector's signoff before the task can be considered complete. (A-02-XX)

5. Review all existing maintenance intervals for tasks that could affect critical aircraft components and identify those that have been extended without adequate engineering justification in the form of technical data and analysis demonstrating that the extended interval will not present any increased risk and require modifications of those intervals to ensure that they (1) take into account assumptions made by the original designers, (2) are supported by adequate technical data and analysis, and (3) include an appropriate safety margin that takes into account the possibility of missed or inadequate accomplishment of the maintenance task. In conducting this review, the Federal Aviation Administration should also consider original intervals recommended or established for new aircraft models that are derivatives of earlier models and, if the aircraft component and the task are substantially the same and the recommended interval for the new model is greater than that recommended for the earlier model, treat such original intervals for the derivative model as "extended" intervals. (A-02-XX)

6. Conduct a systematic industrywide evaluation and issue a report on the process by which manufacturers recommend and airlines establish and revise maintenance task intervals and make changes to the process to ensure that, in the future, intervals for each task (1) take into account assumptions made by the original designers, (2) are supported by adequate technical data and analysis, and (3) include an appropriate safety margin that takes into account the possibility of missed or inadequate accomplishment of the maintenance task. (A-02-XX)

7. Require operators to supply the Federal Aviation Administration, before the implementation of any changes in maintenance tasks intervals that could affect critical aircraft components, technical data and analysis for each task demonstrating that none of the proposed changes will present any potential hazards, and obtain written approval of the proposed changes from the principal maintenance inspector and written concurrence from the appropriate FAA aircraft certification office. (A-02-XX)

8. Pending the incorporation of a fail-safe mechanism in the design of the Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 horizontal stabilizer jackscrew assembly, as recommended in [Safety Recommendation 13 in this report], establish an end play check interval that (1) accounts for the possibility of higher-than-expected wear rates and measurement error in estimating acme nut thread wear and (2) provides for at least two opportunities to detect excessive wear before a potentially catastrophic wear condition becomes possible. (A-02-XX)

9. Require operators to permanently (1) track end play measures according to airplane registration number and jackscrew assembly serial number, (2) calculate and record average wear rates for each airplane based on end play measurements and flight times, and (3) develop and implement a program to analyze these data to identify and determine the cause of excessive or unexpected wear rates, trends, or anomalies. The Federal Aviation Administration (FAA) should also require operators to report this information to the FAA for use in determining and evaluating an appropriate end play check interval. (A-02-XX)

10. Require that maintenance facilities that overhaul jackscrew assemblies record and inform customers of an overhauled jackscrew assembly's end play measurement. (A-02-XX)

11. Require operators to measure and record the on-wing end play measurement whenever a jackscrew assembly is replaced. (A-02-XX)

12. Require that maintenance facilities that overhaul Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 series jackscrew assemblies obtain specific authorization to perform such overhauls, predicated on demonstrating that they possess the necessary capability, documentation, and equipment for the task and that they have procedures in place to (1) perform and document the detailed steps that must be followed to properly accomplish the end play check procedure and lubrication of the jackscrew assembly, including specification of appropriate tools and grease types; (2) perform and document the appropriate steps for verifying that the proper acme screw thread surface finish has been applied; and (3) ensure that appropriate packing procedures are followed for all returned overhauled jackscrew assemblies, regardless of whether the assembly has been designated for storage or shipping. (A-02-XX)

13. Conduct a systematic engineering review of all transport category airplanes to identify means to eliminate the catastrophic effects of a system or associated structure failure in the horizontal stabilizer trim system jackscrew assembly, and, if practical, that all future transport category airplanes incorporate such fail-safe mechanisms. (A-02-XX) (TO BE REVISED)

14. Modify the certification regulations, policies, or procedures to ensure that new horizontal stabilizer trim control system designs are not certified if they have a single-point catastrophic failure mode, regardless of whether any element of that system is considered structure rather than system or is otherwise considered exempt from certification standards for systems. (A-02-XX)

15. Review and revise aircraft certification regulations and associated guidance applicable to the certification of transport-category airplanes to ensure that wear-related failures are fully considered and addressed so that, to the maximum extent possible, they will not be catastrophic. (A-02-XX)

16. Issue a Flight Safety Information Bulletin directing air carriers to discourage their dispatch and maintenance control personnel from engaging in in-flight trouble shooting. (A-02-XX) (TO BE REVISED)

 

     
     

FAA's sloppy inspections draw denials, not change

The National Transportation Safety Board issued a chilling finding Tuesday: The failure to grease a single jackscrew on the tail of Alaska Airlines Flight 261 caused the jetliner to plunge into the Pacific Ocean on Jan. 31, 2000, killing all 88 aboard.

The airline's laxity was not the only cause of the tragedy. The Federal Aviation Administration, charged with policing airline-maintenance programs, had allowed the airline to grease and check the part less frequently. By doing so, the FAA "failed miserably," NTSB acting chairwoman Carol Carmody said.

Add that indictment to a history of failure to hold airlines to strict safety standards, and the obvious conclusion is that the agency isn't performing its primary mission ensuring the safety of the flying public. Yet the FAA's complicity in the Alaska crash comes as it is pushing to expand its role in inspecting older aircraft.

Certainly, potential safety problems with an aging fleet of commercial planes need to be addressed. Even more pressing, though, is the inadequacy of the FAA's current inspection programs. Not until that problem is solved can the agency consider taking on more duties.

Troubling signs of shoddy maintenance are distressingly common. Last week, the FAA proposed a fine against United Airlines for using tape to repair holes in a panel on a jetliner's wing. The same day, it sought a fine against American Eagle for lax maintenance after it flew a jet 88 times with a broken windshield-defogger system. Those lapses, coming at a time when a slump in air travel has airlines fighting for their lives, point to the need for a reliable program to ensure maintenance corners aren't being cut.

Yet the FAA has repeatedly failed to meet that goal. Instead, it has a history of making ambitious promises after airline disasters that it doesn't keep.

In 1996, for example, a ValuJet airliner crashed in Florida when oxygen canisters that should never have been on board ignited a catastrophic fire. A chastened FAA, which had ignored warnings from its own workers that ValuJet was unsafe, promised more vigorous inspections. But a program it set up in 1998 failed to catch mounting signs that Alaska's maintenance was lax and required greater scrutiny.

Even now, nearly three years after the Alaska crash, the FAA has failed to follow through on failings highlighted after the crash, including the lack of systematic analysis of maintenance data.

This week, despite the NTSB's rebuke, the FAA is still in denial. Letting Alaska lubricate and check a crucial mechanism less frequently "was well within industry norms," an FAA spokesman said. In reality, the FAA coddled the airline by giving it more leeway in handling maintenance of the jackscrew.

The FAA's failure to learn from its mistakes raises serious questions about its ability to police routine airline maintenance, much less take on the job of inspecting the more than one in five jetliners built before 1987 that the major carriers still fly.

Airlines have proved that they can't be trusted to police maintenance on their own. That's why the FAA has to fill that role. But first it needs to face up to its shortcomings, rather than deny them even in the face of actions that contributed to 88 deaths.

As the NTSB's Carmody said, "The public trusts the government to ensure the safety of flight." Many changes are needed before the FAA earns that trust.

 

 
 
 
      

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