Aviation Accident Summaries

Aviation Accident Summary DCA92MA044

JAMAICA, NY, USA

Aircraft #1

N11002

LOCKHEED L-1011-385-1

Analysis

IMMEDIATELY AFTER LIFTOFF THE STICK SHAKER ACTIVATED, AND THE FIRST OFFICER, WHO WAS MAKING THE TAKEOFF, SAID 'YOU GOT IT.' THE CAPTAIN TOOK CONTROL, CLOSED THE THRUST LEVERS, AND LANDED. HE APPLIED FULL REVERSE THRUST AND MAXIMUM BRAKING, AND TURNED THE AIRPLANE OFF THE RUNWAY TO AVOID A BARRIER AT THE END. A SYSTEM DESIGN DEFICIENCY PERMITTED A MALFUNCTIONING AOA SENSOR TO CAUSE A FALSE STALL WARNING. THE SENSOR HAD EXPERIENCED 9 PREVIOUS MALFUNCTIONS, AND WAS INSPECTED AND RETURNED TO SERVICE WITHOUT A DETERMINATION ON THE REASON FOR THE INTERMITTENT MALFUNCTION. THE FIRST OFFICER HAD INCORRECTLY PERCEIVED THAT THE AIRPLANE WAS STALLING AND GAVE CONTROL TO THE CAPTAIN WITHOUT PROPER COORDINATION OF THE TRANSFER OF CONTROL.

Factual Information

PLEASE SEE NTSB BLUE COVER REPORT PB93-910404, AAR-93/04.

Probable Cause and Findings

DESIGN DEFICIENCIES IN THE STALL WARNING SYSTEM THAT PERMITTED A DEFECT TO GO UNDETECTED, THE FAILURE OF TWA'S MAINTENANCE PROGRAM TO CORRECT A REPETITIVE MALFUNCTION OF THE STALL WARNING SYSTEM, AND INADEQUATE CREW COORDINATION BETWEEN THE CAPTAIN AND FIRST OFFICER THAT RESULTED IN THEIR INAPPROPRIATE RESPONSE TO A FALSE STALL WARNING. (NTSB REPORT AAR-93/04)

 

Source: NTSB Aviation Accident Database

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