空難調(diào)查報告美國航空96號班機

1、IPB - 219 3 7 0 AIRCRAFT ACCIDENT R E P O R T . AMERICAN AIRLINES,INCORPORATEDMCDONNELL DOUGLAS ONTARIO,CANADA,J U N E T r a n s p o r t a t i o n Washington, NEAR WINDSOR, 12, 1972 F e b r u a r y 1973 BY:U. S.5285Of22151RoyalPB2193 7-0CNAIRCRAFT ACCIDENT REPORTAIAMERICAN AIRLINES, DOUGLASINC.T R A

2、 NNEAR WINDSOR, ONTARIO,CANADAJUNE12, 1972P-0T A TI0NSIIAIRCRAFT ACCIDENT REPORTAMERICAN AIRLINES, INC.DOUGLAS.WINOSOR, ONTARIO, CANADA 12, 1972ADOPTED: FEBRUARY 28.1973TECHNICALAccession No.REPORT STANDARDPAGE. Report No.Title and SubtitleAircraftAirlines, Catalog No.DateDouglas28, 1973Organization

3、nearCanada, June1972.CodeReport No.Unit No.PerforOrganizationAddressTransportation Safety Boardof Aviation Safety or Nc.C.20591Period CoveredIIAgency Name and AddressAircraft Accident Report1972AgencyJuneTRANSPORTATION SAFETY BOARDUashington.C. 20591NotesChisaircraft Safety American rhrn the Douglas

4、 X-10-10,damaged substally cargo compartment door separated from the aircraft in fligh 11,750 feet meanlevel.The separation caused rapidin turn, caused failure of the floor over the bulk cargoTha separated door caused minor damage to the door and sub-surface of the left stal damage to the leadin sta

5、bilizer. andwere 56 passengers and a crew of 11 aboard the nine passengersinjuries.Nationalthis accident was the Safety Roard engagement ofthat the probable cause of latching mechanism foraft bulk the airplane for flight.Thethe door to be and the latct.doorpreparation ofof the door latching mechanis

6、mthe latches were not fully when, in inRapidIn- PlightRelease to public; distribution I-of Pages41 Ciarrification this report) (of this page)UNCLASSIFIED1765.2.TABLE OF CONTENTSSynopsis. . . . . . . . . . . . . . . . . . . . . . . . .1.7l.R 41.152.2. I2.2Histo

7、rythe . . . . . . . . . . . . . . . . .toAircraft. . . . . . . . . . . . . . . . . . . . . . . . .Information. . . . . . , . . . . . . . . . . . . , . . .,. . . . . . . . . . ., . . . . . . . . ., . . . . . . . ., . . . . . . . . . . . . . . . . . . . . .Tests andAnalysis a.n.d. . . . . .s . .,. . .

8、, ., . . . . . . . . .(a). .,., . ., ., . . . . . . . . , . . , .3. Appendix A. . . .,.,. . . ., . . . . . . . . . ., . . . . . . . .Transcript , . . .,., . . . . , . . . . . . . .andAppendix CAircraftEAppendix FAppendix. . . , . . . . .andt u and.NATIONAL SAFETY C. 205911973Adopted:IIAMERICAN AIKLI

9、NES. INC.NEAK WINDSOR.1972CANADA, JUNE 1. INVESTIGATION SYNOPSISHistory of theAmericanaflightAirport.at York. Flight 96aCalifornia. toYork, with InsMichigan parted 1436its of International1972. 46Airport at after resultondeparture. The delay,air traffic control.at 1836. ThisFlight 96 arrived atoffli

10、ght was without incident.Fuel. cargo. andwere loaded!andhepounds,lastcomputedumto behulkunderprior to dispatch ofcompartment.flight wasThe cargo door.servicewho difficulty dthetothestated that tie listeneddoorto stopdoor handle.small venthandlc is designed to which is locatedcargo door. toa cam on e

11、ach of24-hourI. .1.5Crew3,.,of an adjustment to the permit electricswitchof thr latches.1.8 Aids to NavigationNo AirworthinessDirectiveThere werereportedaids during theis equipped with a full instrumentcargo doorsin ataccidcnt.ServiceHowever.Douglas whichlatchwhich was utilized bycrewto the electric

12、al wiring toapproach.May 30, 1972.of thrtor. hadissued1.9cargo door latch actuator wiring with American Airlines hadtime of the accident mandatory. The reason forof this bulletin was stated in wire. with this nor was thebulletin as:All communications with Flight 91routine and in accordance with esta

13、blished pro-cedures.were no reported1.10 Aerodrome Ground FacilitiesDetroit Metropolitan WayneAirport south-Three operators havelatch actuatorsis located approximately west of Detroit.statutecargo doors.trihutcdLatchfailure isrcducineThis con-is north latitudewestat aof airport is operated continuou

14、sly.output torque to thelevel.Runway 03dition may prevent electricalleft isand construction. with It is equipped with high-ingtorque necessitates theofto provide200ininlights approach flashing ensitylights with circuitand high-intensit) approach lights. lights arc equipped with andandlatch

15、ropactuators will torunway zone lights.with touchdownallconditions.''andequipmentwcrcfollows:1.72.5003.000 gallonThe surfaceWayneforat Detroit1Countytu and wcrc. in part.the17511Van.feetfeet overcast.to visibility7 knots.retting 29.85.wcrconandwind point 70" F.shifts.visibilityknots.and

16、fog.I4It isdigital recorder with ofrecordingassociated data.ofwerefrom their fullywere 0.35center stop positions.d positions.inchis inchover.tape. information is oraircraftwhichseriallyin digitalof hours oftracks coveringwhichofindicatedthatrecordrr was the time the doorfrom it that rhc incident occ

17、urrednormally up ob crew'sat an altitude ofbolts was less thanits position.normalactuatorforand taken tocxamination and disassembly.11.750However. the data recorded after limitgear trainoperatedlimit switch opcncd.I: was determined thatswitchcloscd. manually untilfullytheincident wasaberrant.lit

18、tle information was obtainedof inadcquacics ofrecording wastheinstallation in this particular data recorder whichto affect thewasinches. 11.040loadactuator.asofrccorder.unit was given anIn addition toaircraft100 cockpitflight datawith a Fairchild recorder (CVK).which2.000 pounds,1,5002.600 pounds. V

19、olt-CVKfrom 28 Vto 13 Vtaperecovered intact, and a transcript1,500wasacrcprofperrincnt communications is included in dix with a voltage of 13 Vand2,000volt-ofapounds wcrc age of 13 V With acrept with the unit crept with 1.1 2and a current of 13.5 ampere.2.600unit The clutch wasofairplaneofin aftV DC

20、 anddoor which2.900 pounds.with original motor hadtuatordoorthedoor frame.sill, whichac-fourdooruponThe rollers wcrcwere basically undamaged.showed that a high-compression fromlatchesto and, except second rolleron to the doorlatch linearThis wasfromfront. theyactuator gearfrom inhow. dooractuatorofb

21、ushing on the actuatorsupport brackethowcwr.hadwas hanging by its anddoorapproximatelylog actuator supportontwo bolts which structure werewires.notin flight.ofAof onewasto thedoorskinThe ondoor skin which wasfoundfourwith in bracket andnotcloscd. with engaged, tltcwcrc about 0.375 ofinch withoutboar

22、d side of rhc relativeinatevidrncrwith the in filled with partspaint5ing systems. Althoughleft rudder pedal wasofsupport bracket mount structure.um relative motion of 1.05 inches.it fittedindicated aparts pedalvarious following:the left of inpit revealedaft cargo door,The door connected. the dooring

23、 ifddoor onandlatch lockpins arc1.steering system was positioned approximatelyleft because of theThe system is designed closing andhandle arc not in placeprevent stow- therudderinput signal.system was with thethis operatedoperated from the controltorque link the nose The elevatordixonrected; link fr

24、omto the horizon-system normally.dor2.systemoperable through-torquecontrols -.and out itsrangc: however. the input loads werehadfracturedin tcnsion near it5 _._ _ - higherseparatednormal.I-3.stabilizer trim switches on the control wheel operated normally: however,position indicator was inoperative.b

25、yinches and could not be pulledhorizontal torque tube was bent slightly,4.ruddercontrol wasand it was out of its bearing onforwardright; however.trim would not ventis attached totorqueposition the rudder toleft.tube,in place.downward direction.door guardofcabin floor damaged ahad failednumber ofengi

26、ne and flight control systemThe linkage from the torque tube to thepin mechanism was intact. except that the pivotcables which were beams that area. obscrucd:throughfloorfollowing damage waspoint was brokcn on theverts vertical push-rod motion (fromto horizontal lock-tube motion.which con-handle) fo

27、rward1.Controlof the lock tube was bent outboard.door frame was partially fractured in the areaThe rightNo. 6) theelevator cablcs (No. 5downward bycabin floor structure.handof this bend.Thewere withdrawnbeyond their normal unlocked positions.andcargorhc hydraulic powerwarningthe main wheelelevators

28、were operable: however,than normal control forces were required.nox steering system. the control, and the No. 2 engine control systemsBoth left-handcables wereout ofNo. 4 cablerated.left tcnsion regulator. and chc No. 3 cableout of its swaged fitting tocrank.warning light system wascockpit aft tocar

29、go door frame. NoneThefoundcargo doorplug onofcircuitwhichpowcr to2.Systemcarp doors and warning systems was founddoor. the lock d limit switch.to The No. 3cable waswarning switch, closcdtheirthefrombycollapsed floorand could notpedal mechanism hadmoved.rudder its The structure.were found in theward

30、 position and was jannncd.power systems, or inbrakes orleftlowcr crank (cable No. 1)and6a dislocated injury fromduringandstruck by All otherahowever,rudder trim in limitedtoneutral towerr friction slidorof theeventstrailing edge right trim.thethetime until as follows:3.Thestabilizerup and down by co

31、uld bcThere was noalternate electrical trim decompressioneither control fromswitches on theitself to theand flight attendants as aexplosive sound and a white gray fog whichthroughoutcabin. The door toleft-hand manual trim suitcase handle cables had failed, and both right- hand cables were preloaded.

32、 In cockpit anddoorand several ceilingofinof the cabin fell down.to seatpassenger in theAintloortrim stabilizerbothmanually with functioning. p. ositionup and struck aThe horizontaltorTheinwereflightforwardwho was the stabilizer(No.135 and4.2position indicator136) had failed.cablesarea,two flightthr

33、own from this area. seated at the floor. which baggageonaft were thrown tointo below.circularNo. 2 engine throttle. fuel shutoff cables had alltloor sectionfrom the floor.andfailed.The hydraulic, fire. andoff valves wcrc in theirOf the eightthat their firstattendants,was toforautomaticoperate wasfor

34、at 14,000that altitude,flightoxygensystemis 1.13 Firesystem didat Exit There was no fire.obtainedcockpit onthe crew tharairplane.1.14Aspectssystem toin flightofaccident was survivable.andAllat Exit to the cockpit forairplaneescape mally.six of its eightexits.nor-variousfor exitsand the two cabin wer

35、eants who sustained localat flightcaptain.attendants togency landing.for an an1Testsoftime (8 tuminutes)conducted ato deter-mine ifcould be pressurized with with to hrief the public addressof other flightpositionexit door open and rhc nylon cur-vent doortain acting as a sed cnvcloconducted topointed

36、 instructions forslideA number ofnecessary handle byan lockpin stowforcingaft door linkage positional belongingsandthatwithout was veryloca-useful in tion. coulddifferential , prcssurc. Above 5the curtain wasinto lost.'(vent door and pressurization wasscatcdfloor section weretu.were viciofthatfo

37、rce re-passengcrs seated inceiling panel.of thethe handle was approximatelythe door linkage was forcedattendantstoarea.topounds.assignedExits 41. and 4K werein the forwardlockingdid notovcrcenrcr,wasItthatlock was dcflcctcd, wit hdoorindicatorindicator switch canactuatedrollout ofDuringairplane,with

38、 thaninchof cciling panelsdown. Whento a stop. the cabin lightslighting systemairplanc wentilluminated. and signalwas nay in(three ontwo rear exits.of2.ANI)Sevacuation cockpit crew.ofsix exit of'by2.1initiating factorthis accident war the4L and usedin that deployedseparation of thecargufloordoor

39、.Structuralarea.Thrdoorthat the door which ,at-door hadtotwo topacks fellout. Most pas.nottheandindoorhorh failed intoairplane and wcrc waitingThe of one of doors furtinn prucccdcd smoothlythat two to beandby athrough exits by apathceilingbyflightin 30tolinkagesnot that norenough toposition, and for

40、cestheAccordingJoor weretocrank andshould have been 0.47 inch for thisextension.With aa 4.5displace.door would have whichstrength of 6.600 pounds.4.5mation. sincedcflcctivnr, andsufficient tu anmanufacturerwas an approxi-system.riggingrhe loadallthe door larches are full?on eachlatchescould norThese

41、 pins rhenaprevent The this fullyinrhe larches did nornot have stowed.door saidoperated thedid nothandledoorto forcewithandvent door. which isby rhc handle. did norproperly. AThe samehaveindicaror switchcon.tact. which. in thispreventsThus.warningthe doorwaspressurized bulk cargo outside atmosphere

42、duringandclirnbour9I , . .AANI) HEARING1.was no public3.A preliminarythis accidentby the SafetyAugust 22, 1972.Preceding page blank.,.17APPENDIX CbvThe airplane waswas manufacturer on July 28. accident.was poweredaregistrationIt was receivedAmerican Airlines from the2.142of flying time attime of 197

43、1.gas turbine engines. The No.Electric451208. was installed on February 17, 1972.had aengine, serialtime ofNo. 2was installed on March 19, 1972, and had ahours.No. 3 engine.of 177 hours.thatinstalled on Maytotal time of 920 hours. 1972, and had a totalThe airplane recordsnumber 451298.had beeninacco

44、rdance withand FAA Dpany18APPENDIX DOF PERTINENT COMMUNICATIONS FROM COCKPIT VOICE RECORDER. DOUGLAS MAIRLINES FLIGHT 96WINDSOR. CANADA. JUNELEGENDCAMCockpit area microphone Radio transmission fromVoice idcntificd asor sound-1-2-3Voice idcntificd asOfticcrVoice identified as Second Voic

45、eControl Detroit Metropolitan AirportRadar East Metropolitan AirportLCDEClevelandCenter.Radar ControllerARERadar Fast Metropolitan Airport Unintelligible wordNonpcrcinent wordcontinuityQuestionable text Editorial inscrrion#19.-I.AIR GROUNDSOURCE TIMESOURCE-T-IMECONTENTCONTENTCAM-1(Okay,your forward

46、gear has along ways to go)LCAmerican ninety-six maintaincontact departure one eighteen fourheadingOnefour maintain runwayAmerican, eh, ninety-sixCAM-?And American ninety-six, your frequency, we'reoff Detroit MetroDEAmerican ninety-six Detroit departure radar con.tactand maintain six thousandOkay

47、, you want us to climbmaintainthousand, American, uh, ninety-sixDERoger American ninety-six turn heading zero six zeroRight to zero sixninety-sixCAM-IOkay, you got 'em?hCAM-2tiSOURCESOURCE &TIMECONTENTCONTENTCAM-2Flaps, upCAMSound offlap leverCAM-1nine zero, you gotCAM-2Slats.NCAMSound of clickCAM-ICAM-2CAM.?Gear handle to *Sound of clickCAMUAIK GROUND COMMUNICATIONSSOURCESOURCECONTENTAh, correction was thatthree zero?Two three zero American ninety-six report reachingRW - IOkay, American ninety-sixNinety *(T