Accident Details
Probable Cause and Findings
The flight crews' inadvertent setting of the parking brake during flight resulting in the airplane being landed with the parking brake set and failure of all 8 main landing gear tires during the landing rollout.
Aircraft Information
Registered Owner (Current)
Analysis
History of Flight
On March 11, 2004, about 0653 eastern standard time, an Airbus Industrie A300F4-605R, N682FE, operated by Federal Express Corporation as flight 1954, a Title 14 CFR Part 121 scheduled domestic cargo flight, had a failure of all eight main landing gear tires, during the landing roll on runway 27 right at the Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida. Visual meteorological conditions prevailed. An instrument flight rules flight plan was filed. The airplane received minor damage. The two airline transport-rated pilots reported no injuries. The flight had originated from Newark, New Jersey, at 0430.
The Captain stated to the NTSB Operations Group during an interview that she deadheaded to FLL on March 9, 2004, to begin the flight sequence. She had never met, nor flown with, the FO before this sequence of flights. They flew together from FLL to EWR, the night before the landing incident. There was a crew break at EWR but no hotel was provided. She stated that she slept for 1½ hours and the FO slept for about 2 hours. They gathered the flight paperwork and proceeded to the aircraft together. The airplane preflight was accomplished. The flight was catered. She stated that the #2 battery had been replaced. They were given the paperwork for the alternate brake check. They started to pushback. They then started to taxi and had not moved 10 feet when they received a #2 battery overheat warning. It took about an hour for maintenance to resolve the problem. Again, the airplane was pushed back and a takeoff was made on runway 4L. Inbound to EWR, she heard popping and clicking sounds in the cockpit, perhaps caused by the pressurization system. She stated that she decided to try to narrow down these sounds on the next flight leg.
On the flight leg from EWR to FLL, leaving 10,000 feet, a vibration could be felt in the floorboard every 3 to 5 seconds. She wrote it up in the maintenance log. It could also be felt in the circuit breaker wall and other places. The flight was normal at FL 350. At the top of descent, the FAA alternate brake check was accomplished. She stated that she gave the written procedure to the first officer to read while she accomplished the procedure. The First Officer had never seen the form. It was daylight by this time. The BRK-A/SKID switch was pulled out and positioned to the ALTN-OFF position. The BRAKE FAIL light came on. The brake pedals were then depressed. A chime was heard. She stated that when the brake pedals are depressed, you get "ECAM." Usually the brake pressures were about 2,500 psi; however, this time, the left brake pressure indication was 2,100 and the right brake pressure indication was 2,500. During a normal preflight, the alternate brake system is checked. This was accomplished in FLL and EWR. Both times the brake pressures were symmetrical with 2,500 PSI indicated on the gauge but during this in-flight check, they were not. She stated that she wrote it up in the maintenance log. The BRK-A/SKID switch was then returned to the NORM/ON position. The procedure was discussed with the First Officer. He had never seen this procedure before. She stated that she wanted to trouble shoot the system. The BRK-A/SKID switch was then selected to ALTN/ON, like she does on the preflight. A chime was audible. The BRK-A/SKID switch was then selected to NORM/ON. She stated that she wrote it up as she saw it and then asked the First Officer to review the write-up.
The First Officer was the flying pilot. A descent clearance was obtained and a descent was initiated. The checklist was accomplished by the pilot-not-flying, the captain, at 18,000 feet. Everything was normal. They landed on runway 27R at FLL, running about an hour late. The Before Landing checklist was accomplished. At the point where it says, brakes checked, she normally points to the items while she is looking at them. The BRK-A/SKID switch was NORM/ON and there was no pressure indication on the alternate system pressure gauges. She checked the REL bars on the ECAM; they were there and she called, "checklist complete." Before landing, she commented that the runway was clear. The First Officer made a nice landing in the touchdown zone. She called, "spoilers deployed," and asked the First Officer, "are you braking?" He said, no. The deceleration was noticeable. Tower said they were "rolling the equipment." She asked the First Officer to ask the tower what they saw. "Smoke and Fire," was the answer. When the airplane came to a stop, she set the parking brake, moved the throttles to idle, and positioned the fuel levers "down." The First Officer got out of his seat and unlocked the cockpit door. She ran through the evacuation checklist by shutting things down. She noticed emergency equipment arriving in front of the airplane. She told the First Officer that we will evacuate. The First Officer pulled the APU fire handle. The First Officer asked to fire the "bottle" but she said, no. The First Officer asked which door to open. She said, the right side, and then told him not to open it until she said so. She also told the First Officer to make sure he had the HAZMAT paperwork. She then turned the battery switch back on and asked the tower if there was still fire. She never got a reply from the tower. The battery switch was turned back off. The cabin door only partially opened. The First Officer had to push the door open. The slide started to deploy and inflated normally. She never did smell any smoke or see any fire. After the evacuation, the First Officer walked over to a fireman and said, "Here's the HAZMAT paperwork."
The Captain stated that after landing, she expected a normal rollout but got uncommanded braking instead. She had performed the in-flight alternate braking system operational check before but it had been a while. She has been on the A-300 almost 9 years. She has performed the procedure more than once but she was not sure how many times. She had never written one up before. The brake pressures were always about 2,500 psi and symmetrical. This has never been a problem on the ground either. No other abnormal indications were noted. Both the Captain and First Officer confirmed that indications were normal on landing. The Captain stated that the parking brake was not set until after landing. She stated that she did not set the parking brake in flight. She positioned the BRK-A/SKID switch from NORM/ON to ALTN/ON and got a "ding" and a message. She made note of the brake pressure and then positioned the BRK-A/SKID switch back to NORM/ON. She did not recall how many chimes there were during the test. She stated that there were no unrelated abnormals during this brake checking sequence. The brake pressures went back to zero and were zero on the brake check before landing. She stated that it was not "challenge and response" on the landing check. I said, "brakes checked," and the first officer verified it. She stated that she did not set the parking brake until after the airplane was stopped and the evacuation was being accomplished. She stated that there is no formal training on this procedure. "We have a flight test department." If we are going to do it, we should see it in the simulator. The form should spell out what lights and what ECAM indications you should get. It only asks, "pressure or no pressure?" On the Before Landing checklist, "Brakes Checked," you are looking for no pressure, zero pressure.
On rollout, there was "some releasing." She stated that there were no landing gear system warnings. It looked like everything was going fine. She did not use the brakes but she always has her feet on the pedals. The winds were calm, light. No auto brakes were used; they discussed that they were going to use manual braking. She asked if the first officer was braking. She stated that it felt like a "non event," not that severe, and the nose came down normally. The deceleration was not as severe as when medium auto braking was used. She stated that she did not use the brakes. She did not callout 80 and 60 knots because they went "right through them." After the airplane came to a stop, she pulled hard on the parking brake. She stated that the reason she selected the ALTN/ON position was to get further indications in order to make the write up complete.
During the in-range call to "ramp," she stated that there were two write-ups, one more significant than the other. At 18,000 feet on the in-range check, she pressed the "recall" button. The only things indicated were autothrottles inoperative and battery inoperative. She expected to see this and then cleared the ECAM. She stated that the emergency evacuation checklist was not performed using the "challenge and response" method. She did it and then read the checklist from the QRH [Quick Reference Handbook]. The first officer was taking care of the door operation. The parking brake was not previously set. She set the parking brake. She left it set and did not release it. You must be told that the chocks are in before you release the parking brake. She has not seen the maintenance sign-off of the write-ups she made. On deceleration during landing rollout, she observed, "spoilers deployed," on the ECAM. She was unsure if the reverser unlock lights appeared or how much engine reversing was accomplished. The airplane tracked straight down the runway. She thought the emergency checklist was adequate. No injuries were sustained as a result of going down the slide.
The In-Flight Alternate Braking System Operational Check procedure was different from the Alternate Braking preflight check. During the Alternate Braking preflight check, the parking brake is normally already set. The BRK-A/SKID switch is selected to ALTN/ON, the brake pedals are pressed, and then the parking brake is set. She stated that no one would ever set the pa...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# MIA04IA056