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Aviation accident DCA99MA007

MINR · Boeing 737-200 · 1998-11-01 · ATLANTA, GA, USA

Event

NTSB number
DCA99MA007
Event ID
20001211X11399
Type
Accident
Date
1998-11-01
Location
ATLANTA, GA, USA

Injuries

Highest injury
MINR
Fatal
0
Serious
0
Minor
13
Uninjured
92
Total aboard
105

Aircraft

Make
Boeing
Model
737-200
Registration
EICJW
FAR Part
121
Engines
2
Damage
SUBS

Conditions

Light
DUSK
Weather
VMC

Probable cause

(1) the capping of the incorrect hydraulic line by mechanics, which led to the failure of hydraulic system A; (2) the mechanics' lack of experience working with the Boeing 737 hydraulic system; and (3) the maintenance controller's failure to ascertain more information regarding the leaking hydraulic line before instructing the mechanics to cap the line and deactivate the right thrust reverser. Contributing to the cause of the accident were (1) the asymmetric directional control resulting from the deactivation of the right thrust reverser; (2) the depletion of the left and right inboard brake accumulator pressure because of the flight crew's use of the rudder pedals with only the left thrust reverser to control the direction of the airplane down the runway; (3) the failure of the right outboard brake because the airplane was slowed without the use of the left and right inboard brakes and was traveling at a higher-than-normal speed and with heavy gross weight; (4) the failure of the right outboard brake after one of the right outboard pistons overtraveled and unported its o-ring, allowing system B hydraulic fluid to deplete and the left outboard brake to fail; and (5) the mechanics' improper use of the illustrated parts catalog for maintenance and troubleshooting and the maintenance controller's failure to use the appropriate documents for maintenance and troubleshooting.

Source

Authoritative
NTSB CAROL
Machine
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