Philadelphia, PA, USA
N113UW
AIRBUS A320 - 214
Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nosegear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.
HISTORY OF FLIGHT On March 13, 2014, about 1830 eastern standard time, US Airways flight 1702, an Airbus A320, N113UW, experienced substantial damage after the captain rejected the takeoff after rotation on runway 27L at Philadelphia International Airport, Philadelphia, Pennsylvania. The airplane came to rest on the edge of the runway, and the crew and passengers exited via the emergency slides. Of the 149 passengers, 2 pilots, and 3 flight attendants on board, 2 passengers reported minor injuries related to the evacuation. The airplane was substantially damaged. The flight was operating under 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from PHL to Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida. Day visual meteorological conditions prevailed at the time. The accident occurred on the third flight of the day for the flight crew. The first two flights from Charlotte International Airport (CLT) to Tampa International Airport (TPA), then to PHL, were uneventful. The inbound flight to PHL arrived on schedule at 1649, and the accident crew changed gates and airplanes for the scheduled 1750 departure to FLL. According to crew interviews, upon arrival at the accident airplane, the first officer, who was the pilot monitoring (PM), prepared the cockpit while the captain spoke with the dispatcher. The first officer initialized the flight management computer (FMC) with the air traffic control (ATC)-provided flight plan and manually entered the departure runway into the FMC. The ATC route clearance verification procedure is defined in the US Airways standard operating procedures (SOPs) and is performed for every flight. Both pilots stated during postaccident interviews that they verified the ATC routing loaded into the FMC while still at the gate before pushback; however, neither pilot realized that the departure runway loaded into the FMC was runway 27R instead of the assigned runway 27L. Flight 1702 pushed back from gate B8 about 1752, and the taxi out was normal. The weather reported at 1754 was clear skies and 10 statute miles visibility, temperature 0°C, dewpoint -21°C, and winds from 290° at 18 knots with gusts to 28 knots (peak winds at 1713 were recorded from 300° and 33 knots). Automatic terminal information service information "Yankee" called for runway 27L as the departure runway. Flight 1702 had been given an expect departure clearance time of 1829, and the captain decided to conduct a single-engine taxi. At 1754:33, flight 1702 received the final weight and balance information for the flight via the aircraft communication addressing and reporting system, and according to the first officer interview, she loaded the weight and balance information into the FMC via uplink. She could not remember if she uplinked the takeoff data or manually entered the V-speeds and FLEX (a reduced takeoff thrust setting) temperature information into the multipurpose control display unit (MCDU). At 1808:20, flight 1702 contacted ground control for taxi instructions; the ATC ground controller advised that the departure runway was 27L and provided taxi instructions to runway 27L. At 1819:29 the tower controller advised the flight crew that they were number six for departure from runway 27L. At 1820:29, the crew started the second engine then conducted a flight control check. At 1821:22, the tower controller advised that flight 1702 would be next for departure, and the flight crew acknowledged their sequence 4 seconds later. The first officer started to read the remainder of the Taxi checklist when she got a call from a flight attendant advising that a passenger was in the bathroom. The flight attendant then told her the passenger was returning to their seat, and the first officer stated that she continued the checklist as the captain was taxiing toward runway 27L. At 1822:35, flight 1702 was cleared to line up and wait on runway 27L. The first officer accomplished the remainder of the Taxi checklist. As the captain taxied onto runway 27L, he noticed that runway 27R had been inserted into the FMC instead of runway 27L and requested that the first officer change the runway in the FMC, which was completed at 1823:10. At 1823:26, flight 1702 was given a heading of 230 degrees on departure and a clearance for takeoff. Flight data recorder (FDR) data indicate that the airplane had a ground speed of 0 knots indicated airspeed (KIAS) for about 11 seconds before accelerating for takeoff. At 1823:34, the throttle levers initially advanced to the MAX CLIMB level and the captain's longitudinal control was moved to the airplane nose down (AND) direction at 1823:41. The throttles were advanced further to the FLEX detent by 1823:43, with the airplane moving about 46 KIAS. According to crew interviews and cockpit voice recorder (CVR) data, when the captain set the thrust levers in the FLEX detent at 1823:45, the crew received an electronic centralized aircraft monitoring (ECAM) message and chime at 1823:47 indicating that the thrust was not set. In response, the first officer stated "engine thrust levers not set." FDR data indicate the thrust levers were briefly reduced to the climb detent then returned to the FLEX detent about 1 second later. The captain responded "they're set" 3 seconds later. According to FDR and CVR data, the first officer did not make a required callout as the airplane's speed reached 80 KIAS. According to flight crew interviews, the captain and first officer noticed that there were no V-speeds indicated on their primary flight displays (PFDs), and FDR and CVR data show that as the airplane accelerated through 86 KIAS as an aural RETARD alert sounded in the cockpit. According to the CVR, at 1823:56, the captain asked the first officer "what did you do, you didn't load. We lost everything." At 1824:03, as the airplane continued to accelerate through 143 KIAS, the captain stated "we'll get that straight when we get airborne" and continued the takeoff roll. The airplane continued to accelerate over the next several seconds, reaching 152 KIAS at 1824:08. At 1824:09, the first officer stated "wh*. I'm sorry", the captain's longitudinal control was brought into the airplane nose up (ANU) direction, and the pitch of the airplane began to increase as the longitudinal control was brought up to 6.9 degrees ANU over the next second as the airplane began initial rotation for takeoff. The airspeed at this point was 164 KIAS, and the nose gear weight on wheels discrete changed to "air" by 1824:10. Over the next 4 seconds, with the nose gear discrete reading "air" and the main landing gear discrete reading "ground" the captain's longitudinal control was pushed into the airplane nose down (AND) direction, and then pulled back in the ANU direction two times, reaching the maximum of 16 degrees in the ANU direction, and a minimum of 16 degrees AND during the cyclic input. The pitch of the airplane, and vertical acceleration followed the variations in longitudinal inputs. As the vertical acceleration decreased in response to the nose down input, the flight crew reduced the thrust levers, and the captain's longitudinal control was pulled again in the ANU direction. The vertical acceleration reached a minimum of 0.121 G as the control was pulled to 16 degrees ANU, the maximum operational value, and the engine throttle lever angles were reduced to idle thrust where they remained for the rest of the recording. By 1824:14, the nose gear weight on wheels discrete parameter changed back to "ground." During the previous 4 seconds, when the nose parameter recorded "air," the main landing gear (both left and right) weight on wheels parameter had recorded "ground," and the maximum radio altitude recorded was 6 feet above ground level (agl), which occurred for only 1 second. Once the pitch reduced to -0.4 degree, the vertical acceleration rapidly increased to 3.7 G, consistent with the gear impacting the runway surface. The pitch parameter was not valid for the rest of the FDR recording. As the vertical acceleration reached its maximum value, the captain's longitudinal input reached a maximum of 16 degrees ANU. The captain's longitudinal control cycled in the nose up and nose down directions over the next 2 seconds. During this variation, the vertical acceleration dropped to 0.47 G, then increased to 1.2 G. As the longitudinal stick was pulled back to over 16 degrees ANU and held at the maximum value, the main landing gear weight on wheel parameters changed to "air" for the next 2 seconds, and the radio altitude began to increase to about 15 ft agl. As the airplane reached 15 ft agl, the longitudinal control moved back to the AND position, and pitch of the airplane again reduced and the airplane began to descend back to the runway surface. The stick was moved again in the ANU direction as the airplane began to descend and, correspondingly, the airplane pitch increased again. Surveillance video obtained from the Philadelphia Airport captured the final impact with the runway. The video shows the airplane impacted the runway first with the tail, then main landing gear, and the airplane then rotated in the AND direction, resulting in the nose gear impacting the runway and subsequently collapsing. At 1824:48, the flight crew advised the tower that they aborted the takeoff as the airplane came to rest on the left side of runway 27L. At 1829:14, the flight crew advised the PHL tower that they were evacuating the airplane. The flight attendants stated all slides deployed normally, except door 2R, which was not deployed due to smoke on the right side of the airplane, and 2L, which did not reach the ground due to the nose gear collapse. DAMAGE TO AIRCRAFT The airplane nose gear collapsed upon impact with the paved runway, resulting in fuselage and engine cowling damage. As a result of the tailstrike, additional damage occurred to the lower aft fuselage section of the airplane, including the aft pressure bulkhead, fuselage, struts, and cross beams. Damage to the left engine occurred after the nose gear collapse due to ingestion of debris. PERSONNEL INFORMATION The Captain The captain, age 61, was hired by Piedmont Airlines on March 3, 1986. US Airways (then USAir) purchased Piedmont Airlines in 1987 and merged operations in 1989. His background was all civilian flying, including flight instruction and flying for a commuter airline for about 5 1/2 years before being employed with Piedmont Airlines. The captain estimated his total flying time at 23,800 hours, including about 7,500 hours as pilot-in-command and about 4,500 hours on the A320. The captain's most recent proficiency check (continuing qualification training) occurred on December 19, 2013. The captain held an airline transport pilot certificate, which included a type rating on the A320 and a first class medical certificate with a limitation that stated "Not valid for any class after May 31, 2014." According to the captain, his medical certificate included a special issuance related to a previous bypass surgery in February 2011. For additional information on the captain's medical condition, see the Human Performance Group Chairman's Factual Report. A review of the FAA program tracking and reporting subsystem (PTRS) database showed no records or reports of any previous aviation incidents or accidents involving the captain. A search of the National Driver Register found no record of driver's license suspension or revocation. The captain was off duty March 6-12, 2014. On Monday, March 10, he woke up about 0700, had a dental appointment at 0900, then rode his bike. His activities the rest of the day were normal. He went to bed about 2200-2230. He turned on the TV, then went to sleep, and reportedly slept well. On Tuesday, March 11, he woke up about 0630-0700. He had an appointment with his cardiologist, which was done by 1330 then he had lunch. He was not sure when he went to bed but thought it was about 2230. On Wednesday, March 12, he was "happy and relieved" because he thought the FAA would approve him for another year to fly. He did not do much that day and went to bed early because he had to be up early the next morning. He thought he went to bed about 2100-2130 and reported no problems sleeping. On Thursday, March 13, he woke up about 0445 and felt fine. He left his home for the airport at 0515 for the 25-minute drive to FLL and caught a 0630 flight to CLT. The 2-hour flight to CLT was uneventful, and he thought he napped about 90 minutes on the flight in an exit row seat. He arrived in CLT at 0830 and signed in for his 1035 trip about 0930. He had a cup of coffee before starting the trip. The accident crew departed CLT about 1132 and arrived at TPA at 1312. The captain ate a meal after arriving in TPA and planned to eat a crew meal during the accident flight. The First Officer The first officer, age 62, was hired by US Airways as a pilot on March 25, 1999; she had been hired as a flight attendant by Piedmont Airlines in July 1973. She started flying in 1986 and became a certified flight instructor for Piedmont Aviation for several years before getting hired by CCAir (a regional code-sharing partner with US Airways) in 1990. She was furloughed from CCAir for a short time before being recalled in 1991 and flew the Jetstream. She was furloughed from US Airways from March 2, 2002, to April 15, 2007, and was trained on the A320 upon returning from furlough. The first officer estimated her total flying time at 13,000 hours, including about 4,700 hours on the A320. The first officer's most recent continuing qualification training occurred on May 15, 2013. She held an airline transport pilot certificate, which included a type rating on the A320 and a first-class medical certificate with a limitation that stated that she must wear corrective lenses and possess glasses for near and interim vision. According to the first officer, she was wearing her glasses on the accident flight, and they came off during the accident sequence. She retrieved a spare pair from her suitcase to read the Quick Reference Handbook during the evacuation. A review of the FAA PTRS database showed no records or reports of any previous aviation incidents or accidents involving the first officer. A search of the National Driver Register found no record of driver's license suspension or revocation. The first officer was off duty March 9-12, 2014. For Monday, March 10, she did not recall when she woke up but said it was probably about 0800 because she had workers scheduled to arrive about 0900. It was a normal day and she stayed at home most of the day but may have also run some errands. She could not remember when she went to bed but it was generally around 2230-2300. She sometimes watched TV in bed. On Tuesday, March 11, and Wednesday, March 12, she awoke and went to bed about the same times as on Monday and her activities were also the same. She felt rested each morning. On Thursday, March 13, she woke up about 0800 and left for the airport about 0930 for the 1035 report time. It was a 20- to 25-minute drive to the airport. Her natural wakeup time was around 0800. She "felt rested, felt great." She ate her lunch at the gate in TPA. AIRCRAFT INFORMATION The accident airplane, an Airbus A320-214 (N113UW), serial number 1141, was manufactured in 1999. The registered owner was US Airways, Inc., and an FAA transport-category airworthiness certificate for the airplane was dated February 4, 2000. The airplane had a maximum ramp weight of 170,635 pounds and a total seating capacity of 159, which included 4 flight crew seats, 5 cabin crew seats, and 150 passenger seats. At the time of the accident, it had a total of 44,230 airframe hours, and the last recorded inspection occurred on March 3, 2014. A review of NTSB and FAA records found that the accident airplane had not been involved in any previous accidents or serious incidents that merited a formal investigation. US Airways used the SABRE Flight Planning System and the Automated Takeoff Weight and Weight & Balance System. Central Load Planning calculated the final weight and balance data using the automated/manual system and applicable station infor
the captain's decision to reject the takeoff after the airplane had rotated. Contributing to the accident was the flight crew's failure to follow standard operating procedures by not verifying that the airplane's flight management computer was properly configured for takeoff and the captain's failure to perform the correct action in response to the electronic centralized aircraft monitoring alert.
Source: NTSB Aviation Accident Database
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