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1、PB88-910406NAflOhiAlTRANSPORTATIONSAFETYBOARDWASHINGTON, D.C. 20594AIRCRAFT ACCIDENT REPORTNORTHWEST AIRLINES, INC.MCDONNELL DOUGLAS DC-9-82, N312RCDETROIT METROPOLITAN WAYNE COUNTY AIRPORTROMULUS, MICHIGANAUGUST 16,1987NTSB/AAR-88/05UNITED STATES GOVERNMENT1. Report No.2. Government Accession No.NT
2、SWAAR-88/OSPB 88-9 104064. Title and Subtitle: Aircraft Accident Report-NorthwestAirlines, Inc., McDonnell Douglas DC-9-82, N312RC, DetroitVletropolitan Wayne County Airport, Romulus, Michigan,4ugust 16,19877. Author(s)9.Performing Organization Name and AddressNational Transportation Safety BoardBur
3、eau of Accident InvestigationWashington, D.C. 20594?12. Sponsoring Agency Name and AddressNATIONAL TRANSPORTATION SAFETY BOARDWashington, D.C. 2059415.Supplementary NotesTECHNICAL REPORT DOCUMENTATION PAGE3. Recipient s Catalog No.,5. Report DateMay lo,19886. Performing OrganizationCode8. Performing
4、 OrganizationReport No.10.Work Unit No.4717c11.Contract or Grant No.13.Type of Report andPeriod CoveredAircraft Accident ReportAugust 16,198714.Sponsoring Agency Code16. AbstractAbout 2046 eastern daylight time on August 16, 1987, Northwest Airlines, Inc., flight255 crashed shortly after taking off
5、from runway 3 center at the Detroit Metropolitan WayneCounty Airport, Romulus, Michigan. Flight 255, a McDonnell Douglas DC-9-82, U.S. RegistryN312RC, was a regularly scheduled passenger flight and was en route to Phoenix, Arizona.According to witnesses, flight 255 began its takeoff rotation about 1
6、,200 to 1,500 feet from theend of the runway and lifted off near the end of the runway. After liftoff, the wings of theairplane rolled to the left and the right about 35” in each direction. The airplane collided withobstacles northeast of the runway when the left wing struck a light pole located 2,7
7、60 feet beyondthe end of the runway. Thereafter the airplane struck other light poles, the roof of a rental carfacility, and then the ground. It continued to slide along a path aligned generally with theextended centerline of the takeoff runway. The airplane broke up as it slid across the ground and
8、postimpact fires erupted along the wreckage path. Three occupied vehicles on a road adjacent to17.Key Wordsairplane configuration; flaps and slats retraction; centralaural warning system; supplemental stall recognitionsystems; circuit breaker; flightcrew standardization;cockpit discipline19.Security
9、 ClassificationI20.Security Classification(of this report)(of this page)UNCLASSIFIEDJTSB Form 1765.2 (Rev. 3188)UNCtiSkED18.Distribution StatementThis document is availableto the public through theNational TechnicalInformation ServiceSpringfield, Virginia 2216121. No. of Pages22. Price142the airport
10、 and numerous vacant vehicles in a rental car parking lot along the airplane s path weredestroyed by impact forces and/or fire. Of the persons on board flight 255, 148 passengers and 6crewmembers were killed; 1 passenger, a 4-year-old child, was injured seriously. On the ground, twopersons were kill
11、ed, one person was injured seriously, and four persons suffered minor injuries.The National Transportation Safety Board determines that the probable cause of the accidentwas the flightcrew s failure to use the taxi checklist to ensure that the flaps and slats were extendedfor takeoff. Contributing t
12、o the accident was the absence of electrical power to the airplane takeoffwarning system which thus did not warn the flightcrew that the airplane was not configuredproperly for takeoff. The reason for the absence of electrical power could not be determined.iiCONTENTSEXECUTIVE SUMMARY. . . . . . . .
13、. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v1.1.11.21.31.41.51.61.6.11.6.21.6.31.6.41.6.51.6.61.6.71.71.81.91.101.111.11.11.11.21.121.131.141.151.15.11.15.21.161.16.11.16.21.16.31.16.41.16.51.16.61.171.17.11.17.21.17.31.17.41.17.51.17.61.182.2.12.22.32.4F
14、ACTUAL INFORMATIONHistoryoftheFIight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1InjuriestoPersons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Damagetothe
15、Airplane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4OtherDamage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Personnellnformation. . . . . . . . . . . . . .
16、 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Airplaneinformation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6WeightandBalance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17、. . . . . . . . . . . . . . . . . . . . . . . .7FlapandSlatSystems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7TakeoffConditionComputer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18、. .9The Digital Flight Guidance System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9StallProtectionSystem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Central Aural Warning System. . . . . . . .
19、. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12CAWS Unit Self-Monitor System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Meteorologicallnformation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20、. . . . . . . . . . . .15NavigationalAids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Aerod
21、romelnformation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16FlightRecorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18TheCockpitVoiceRecorder. . . . . . . . . .
22、 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18The Digital Flight Data Recorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Wreckage and Impact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23、. . . . . . . . . . . .22Medical and Pathological Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26SurvivalA
24、spects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Crash,Fire,Rescue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27DisasterPlans. . . . . . . . . . . .
25、. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28TestsandResearch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28TheCAWSUnit. . . . . . . . . . . . . . . . . . . . . . . . . . .
26、 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28CAWS Sound Spectrum Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29ElectronicEquipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27、. . . . . . . . . .30Cockpit Wiring and Circuit Breakers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30FlapHandleModule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33AirplanePerformance. . . . .
28、 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Otherlnformation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37Northwest Airlines and Republic Airlines Merger. . . . . . . . .
29、. . . . . . . . . . . . . . . . . . . . . .37ProficiencyTraining. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39The DC-g-82 Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30、. . . . .41ChecklistProcedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Human Performance Research Projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43FAASurveillance. . . . . . . . . . . . .
31、. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46Useful or Effective Investigative Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46ANALYSISGeneral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32、_._.47TheAccident . . . . . ._._._. 48The DFDR Readout and Airplane Performance Study. . . . . . . . . . . . . . . . . . . . . .49The Physical Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50. . .III2.5The Central Aural Warning System . . . . .2.6Flightcr
33、ew Checklist Performance. . . .2.7Training. . . . . . . . . . . . . . . . . . . . . . . . . . . .2.8Automated Systems Use. . . . . . . _ . . . .2.9Flightcrew Actions After Takeoff. . . . .2.10The Captain s Hearing. . . . _ . . _ . . . . . . . .3.3.13.24.5.6. . . . . . . . . . . . . . . . . . . . . .
34、 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52. .56.62. .64. .64.67CONCLUSIONSFindings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ._.67ProbableCause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35、. ._._.68RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68GLOSSARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70APPENDIXESAppendix A-Investi
36、gation and Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73Appendix B-Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74Appendix C-CVR Transcript. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37、 . . . . . . . . . . . . . . . . . . .75Appendix D-Visual Displays of Flight 255. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127Appendix E-DC-g-82 Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137ivEXECUTIVE SUMMARYAbout
38、 2046 eastern daylight time on August 16, 1987, Northwest Airlines, Inc., flight 255 crashedshortly after taking off from runway 3 center at the Detroit Metropolitan Wayne County Airport,Romulus, Michigan. Flight 255, a McDonnell Douglas DC-9-82, U.S. Registry N312RC, was a regularlyscheduled passen
39、ger flight and was en route to Phoenix, Arizona, with 149 passengers and 6crewmembers.According to witnesses, flight 255 began its takeoff rotation about 1,200 to 1,500 feet from theend of the runway and lifted off near the end of the runway. After liftoff, the wings of the airplanerolled to the lef
40、t and the right about 35” in each direction.The airplane collided with obstaclesnortheast of the runway when the left wing struck a light pole located 2,760 feet beyond the end ofthe runway. Thereafter the airplane struck other light poles, the roof of a rental car facility, andthen the ground. It c
41、ontinued to slide along a path aligned generally with the extended centerlineof the takeoff runway.The airplane broke up as it slid across the ground and postimpact fireserupted along the wreckage path. Three occupied vehicles on a road adjacent to the airport andnumerous vacant vehicles in a rental
42、 car parking lot along the airplane s path were destroyed byimpact forces and/or fire.Of the persons on board flight 255, 148 passengers and 6 crewmembers were killed; 1 passenger,a 4-year-old child, was injured seriously. On the ground, two persons were killed, one person wasinjured seriously, and
43、four persons suffered minor injuries.The National Transportation Safety Board determines that the probable cause of the accidentwas the flightcrew s failure to use the taxi checklist to ensure that the flaps and slats were extendedfor takeoff. Contributing to the accident was the absence of electric
44、al power to the airplane takeoffwarning system which thus did not warn the flightcrew that the airplane was not configuredproperly for takeoff. The reason for the absence of electrical power could not be determined.VNATIONAL TRANSPORTATION SAFETY BOARDWASHINGTON, D. C. 20594AIRCRAFT ACCIDENT REPORTN
45、ORTHWEST AIRLINES, INC.MCDONNELL DOUGLAS DC-9-82, N312RCDETROIT METROPOLITAN WAYNE COUNTY AIRPORT,ROMULUS, MICHIGANAUGUST 16,19871. FACTUAL INFORMATION1.1History of the FlightOn August 16, 1987, a Northwest Airlines (Northwest) flightcrew picked up a McDonnellDouglas DC-g-82 airplane, N312RC, at Min
46、neapolis, Minnesota, and operating as flight 750, flew theairplane to Saginaw, Michigan, with an en route stop at Detroit Metropolitan Wayne County Airport(Detroit-Metro), Romulus, Michigan, arriving at Saginaw about 1840 eastern daylight time. AtSaginaw N312RC became flight 255 and was flown by the
47、 same flightcrew which had brought theairplane in. Flight 255, was a regularly scheduled passenger flight between Saginaw and Santa Ana,California, with en route stops at Detroit and Phoenix, Arizona.The flight was to be conducted inaccordance with the provisions of 14 Code of Federal Regulations (C
48、FR) Parts 91 and 121. About1853, flight 255 departed Saginaw and about 1942 arrived at its gate at Detroit- Metro.Except fortaxiing past and having to make a 180” turn to return to its assigned arrival gate, the flight toDetroit was uneventful.After the disembarking passengers had left the airplane,
49、 a Northwest mechanic enteredthe cockpit and reviewed the airplane and cabin maintenance logbooks. He stated that nodiscrepancies were entered in either logbook. There was no record of any maintenance having beenperformed on the airplane while it was at Detroit-Metro.About 10 to 15 minutes before th
50、e flight was due to depart the gate, a companytransportation agent brought the flight release package to the airplane.He was met by the firstofficer who told him that the captain was not on board. The first officer inspected the packagewhich contained the dispatch documents, signed the release, and