Crash of a McDonnell Douglas MD-90-30 in Riyadh

Date & Time: May 8, 2009 at 1558 LT
Type of aircraft:
Operator:
Registration:
HZ-APW
Flight Type:
Survivors:
Yes
Schedule:
Jeddah - Riyadh
MSN:
53513/2257
YOM:
1999
Flight number:
SVA9061
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Saudi Arabian Airlines MD-90 was substantially damaged during a runway excursion accident Riyadh (RUH). The seven crew members escaped unhurt. The airplane operated on a repositioning flight from Jeddah. During the flight, the captain discussed the use of manual spoilers during landing with the first officer. He further stated that; as he "had only around 400 hours in the aircraft" as a captain, he wanted to "see the effect' of landing with manual spoilers. He further explained that the flight provided an opportunity to "do it manually" (use manual spoilers) as it was a repositioning flight and, the weather and dry runway conditions were ideal. As such, he discussed the procedure with the first officer and elected to land with the auto ground spoiler system unarmed. The flight was uneventful. During the approach to Riyadh the Landing Checklist was completed, which included the arming of the auto ground spoiler system for landing. After the Landing Checklist was completed, the captain disarmed the auto ground spoiler system with the intention of applying manual ground spoilers after landing. The auto braking system was also not armed prior to landing. The final approach and touchdown to runway 15 Left at Riyadh were uneventful. The touchdown airspeed was 135 knots calibrated air speed (CAS). On touchdown, the captain manually extended the spoiler/speed brake lever, but did not latch it in the fully extended (EXT) position (fully aft and latched upwards). The captain then removed his right hand from the speed brake lever in order to deploy the thrust reversers. The first officer noted the movement of the spoiler/speed brake lever and called "Spoilers Deployed". Since the spoiler/speed brake lever was not fully pulled aft and latched upwards, the lever automatically returned to the forward retracted (RET) position. This movement of the spoiler/speed brake lever was not noticed by the captain and the first officer. In response, the ground spoilers re-stowed before being fully deployed and, a speed brake/flap configuration (SPD BRK/FLP CONFIG) Level 1 Amber Alert occurred. This alert occurred as the aircraft was not yet fully weight on wheels (WOW) and the aircraft still sensed a flight condition with speed brakes deployed and flaps extended beyond six degrees. Six seconds after touchdown on the right main landing gear, the nose gear touched down and the aircraft transferred to a ground condition (WOW on nose gear and main wheel spin up). The SPD BRK/FLP CONFIG alert extinguished when the nose gear oleo actuated ground shift on landing. After touchdown, the aircraft banked to the right and began to drift right of the runway centerline. In response, he applied left rudder, deployed the thrust reversers and applied left aileron. But this did not have any noticeable effect. The captain saw the approaching G4 taxiway exit and in an attempt to keep the aircraft from leaving the runway surface beyond the G4 taxiway exit, he decided to direct the aircraft towards the taxiway. He then applied a right rudder input which caused the aircraft to commence a rapid sweeping turn to the right towards the G4 taxiway exit. The aircraft left the runway at high speed, traversed the full width of the G4 taxiway, and exited the surface at its southern edge. The aircraft then entered a sand section and travelled the distance infield between the edge of the G4 taxiway and the adjacent section of taxiway GOLF. The left main landing gear collapsed during this time. The aircraft came to rest on taxiway GOLF. There was no post impact fire.
Probable cause:
Cause Related Findings
1. The Captain decided to land with manual ground spoilers when the auto ground spoiler system was fully operational.
2. The initiative by the Captain to conduct this improvised exercise contravened the Standard Operating Procedures (SOPs) and the Flight Operations Policy Manual (FOPM).
3. The auto ground spoiler system was disarmed prior to landing.
4. The spoiler/speed brake lever was partially applied manually after landing.
5. The spoiler/speed brake lever was released before it was fully extended and latched.
6. The spoiler/speed brake lever automatically retracted as per design.
7. The ground spoilers never fully deployed.
8. The loss of lift and aircraft deceleration were greatly reduced by the lack of ground spoiler deployment.
9. Brakes were not used in an attempt to control or slowdown the aircraft.
10. The Captain applied a large right rudder input with the intention of directing the aircraft onto the G4 taxiway exit.
11. The aircraft exited the runway at high speed and was travelling too fast to successfully negotiate the right turn onto the G4 taxiway.

Ground fire of a Boeing 747-357 in Dhaka

Date & Time: Mar 25, 2008 at 0827 LT
Type of aircraft:
Operator:
Registration:
TF-ARS
Survivors:
Yes
Schedule:
Madinah - Dhaka
MSN:
22996/586
YOM:
1983
Flight number:
SV810
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
307
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18137
Captain / Total hours on type:
5637.00
Copilot / Total flying hours:
7161
Copilot / Total hours on type:
261
Aircraft flight hours:
99327
Aircraft flight cycles:
18779
Circumstances:
TF-ARS (B747-300) was on a scheduled flight from Medina (Saudi Arabia) to Dhaka (Bangladesh), flight number SVA810. The flight crew consisted of a commander, copilot and a flight engineer. The cabin crew consisted of 15 crew members including one senior cabin attendant. Additionally to the cabin crew, one “off duty” cabin crew member was in the cabin. According to the commander, the flight from Medina and the landing at Dhaka was uneventful. During the landing roll, approximately 50 seconds after touchdown, the flight crew received a call from the tower controller where the tower controller inquired whether the aircraft was under control. The flight crew responded to the call by stating that the aircraft was completely under control and asked what the problem seemed to be. The controller then informed the flight crew that fire was observed at the right wing area. At this point the Aerodrome Fire Operator had already activated the fire fighters as well as the rescue team. As soon as the controller had informed the flight crew about the fire, the flight crew received a No. 3 engine fire alarm. The co-pilot immediately discharged the first engine fire bottle and the flight crew requested firefighter assistance and shut down all engines. The co-pilot waited 20 seconds until the second fire bottle was discharged. At this time the commander called the senior cabin attendant to the flight deck using the public address system (PA). This command was followed by a command to the cabin crew to remain seated. The commander informed the senior cabin attendant of the situation and instructed him to evaluate the situation and to evacuate the passengers if necessary. The senior cabin attendant went back down to the main deck and saw the smoke and the fire through the windows. He then commanded the cabin crew as well as passengers, by using a megaphone, to evacuate the aircraft. The cabin attendant at location L2 (see figure 6-7, page 21) had already operated the emergency exit and started evacuating the passengers. Cabin attendants at locations L1 and R2 (see figure 6-7, page 21) also operated their respective emergency exits. After realizing that smoke and fire were at the right hand side, the emergency exit at R2 was blocked by one of the cabin attendants. All passengers managed to evacuate without serious injuries and the fire department at Zia International Airport managed to extinguish the fire successfully. The damage to the aircraft was later evaluated as beyond economical repair.
Probable cause:
When TF-ARS was decelerating after landing on runway 14 at Zia International Airport, fuel leak at engine No. 3 resulted in a fire within the strut. The cause of the fire was that fuel was leaking through the flexible half coupling to the hot surface of the engine. The fuel leak was because the O-ring and retaining rings were not properly assembled within the coupling and one retaining ring was missing. The IAAIB considers unclear instructions in the aircraft maintenance manual (AMM) to be a contributing factor of the incorrect installation. Another incorrect installation was also found at the flexible half coupling at the front spar for engine No. 1. However there were no signs of a fuel leak in that area, most likely due to the fact that both the retaining rings and the O-ring were within the coupling even though they were incorrectly placed. During the investigation, it was not possible to determine the quantity of the fuel leak. However it is likely that the draining system within the strut of engine No. 3 could not manage the fuel leak. According to the manufacturer, the intention of the draining system is to drain drips or small running leaks. Furthermore the drain was clogged by debris, but IAAIB believes that this was a result of the fire. Two out of six suitable emergency exits on the left side were used (L1 and L2) to evacuate most of the passengers during the emergency evacuation. The reason for not opening doors at location L3, L4 and L5 initially was most likely due to the fact that the commander ordered the cabin crew to remain seated prior to the emergency evacuation. The cabin crew members at locations L3 to L5 most likely did not hear the emergency evacuation command from the senior cabin crew member as he was only using a megaphone. Furthermore these exits were not opened later since the passengers moved aggressively to the opened exits, L1 and L2. The reason for not opening emergency exit UDL at the upper deck was evaluated by the crew to be too risky for the passengers. The flight crew discharged both fire bottles for engine No. 3 without managing to extinguish the fire. The flight crew did not discharge fire bottles on other engines. According to the passenger evacuation checklist (see Appendix 2), the crew should discharge all fire bottles before evacuation.
Findings as to causes and contributing factors:
- Incorrect assembly of the flexible half coupling at the front spar of engine No. 3.
- Retaining ring missing in flexible half coupling at the front spar engine No. 3.
- Lock wire fastened in such a way that the coupling nut might rotate slightly.
Findings as to risk:
- Unclear command made to the cabin crew to start emergency evacuation.
- Cabin crew did not open all suitable emergency exits.
- Flight crew did not follow company’s procedure regarding evacuation.
Other findings:
- Retaining rings and O-ring incorrectly inserted in the flexible half coupling on engine No. 1.
- Pliers used to tighten or loosen the coupling nuts, even though maintenance manual instructs to only hand tight the nuts.
Final Report: