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NTSB/AAR-93/04 PB93-910404

Abstract: This report explains the aborted takeoff and destruction of a Trans World Airlines L-1 0 1 1 airplane, which was scheduled passenger flight 843, shortly after liftoff from John F. Kennedy International Airport, Jamaica, New York, on July 30, 1992. The safety issues discussed in the report include training and procedures for flightcrews in abnormal situations during the takeoff and initial climbing phases of flight, flightcrew control responsibilities for all takeoffs, trend monitoring in airline maintenance and quality assurance programs, the failure of the stall warning system during ground or flight operations, and the location of an airport blast fence. Safety recommendations concerning these issues were made to the Federal Aviation Administration and the Port Authority of New York and New Jersey.

EXECUTIVE SUMMARY

On July 30, 1992, at 1741 eastern daylight time, Trans World Airlines scheduled passenger flight 843, an L-1011, N 1 1002, experienced an aborted takeoff shortly after liftoff from John F. Kennedy International Airport, Jamaica, New York, en route to San Francisco International Airport, California. The airplane came to rest, upright and on flre, on grass-covered soil, about 290 feet to the left of the departure end of runway 13R. There were no fatalities among the 280 passengers on board the airplane, but there were 10 reported injuries that occurred during egress. The flight was operating under 14 Code of Federal Regulations Part 121.

The National Transportation Safety Board determines that the probable causes of this accident were 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.

The safety issues in this report focused on training and procedures for flightcrews in abnormal situations during the takeoff and initial climb phases of flight, flightcrew control responsibilities for all takeoffs, trend monitoring in airline maintenance and quality assurance programs, the failure of the stall warning system during ground or flight operations, and the location of an airport blast fence.

Recommendations concerning these issues were addressed to the Federal Aviation Administration and the Port Authority of New York and New Jersey. Also, as a result of the investigation of this accident, on March 8, 1993, the Safety Board issued safety recommendations to the Federal Aviation Administration that pertained to emergency exit windows, seatbelts in cockpit observer seats, and fire blocking materials.

1. FACTUAL INFORMATION

1.l History of the Flight

On July 30, 1992, at 1741 eastern daylight time, Trans World Airlines (TWA) scheduled passenger flight 843, an L-1011, N11002, experienced an aborted takeoff shortly after liftoff from John F. Kennedy International Airport (JFK), Jamaica, New York, en route to San Francisco International Airport (SFO), California. The flight was operating under 14 Code of Federal Regulations (CFR) Part 121.

There were 280 passengers and a crew of 12 on board. The flightcrew consisted of a captain, first officer, and flight engineer. There were nine flight attendants. When the accident occurred, the flight attendants were seated for takeoff throughout the cabin. Included in the 280 passengers were two off-duty TWA pilots and five off-duty flight attendants. The off-duty pilots were seated in the cockpit jumpseats. Three of the off-duty flight attendants were seated in extra cabin attendant positions. Two were seated in passenger seats. Every available seat was occupied.

The flight was cleared to push back from the gate at 1716:12. At 1725:37, JFK ground control cleared the flight for taxi to "runway one three right, taxi left outer, hold short of [taxiway] November." The length of runway 13R/3 IL was 14,572 feet. (See figure 1). The first officer was at the controls for takeoff. At 1740:10, the captain acknowledged a call from JFK tower that the flight was it cleared for takeoff."

As recorded on the cockpit voice recorder (CVR), at 1740:58, the captain called out "V₁." (See appendix D). At 1741:03, he called "V_R" At 1741:11, the first officer said, "Getting' a stall," and 1.4 seconds later he said, "You got it." The captain said, "O.K." at 1741:13. At 1741:15, there was a sound of a snap, followed by the captain saying, "Oh Jes--." The first officer then said, "Abort, get it on." The flight engineer said, "Get it off." The first officer again said, "Get it on." The flight engineer again said, "Get it off." At 1741:20, the captain said, "What was the matter?" The first officer said, "Getting a stall." At 1741:32, the first officer said, "Stay with it." Then he said, "Stay on the brakes, stay on the brakes." At 1741:38, the JFK tower broadcast, "TWA eight forty three heavy, numerous flames." As recorded on the flight data recorder (FDR), the airplane was airborne for about 6 seconds. Figure 2 depicts selected CVR and FDR derived times and events during the takeoff and landing back on the runway.

The captain told the Safety Board that the takeoff was made using standard TWA procedures. That is, when the first officer is making the takeoff, the captain maintains control of the thrust levers until the landing gear is retracted. The captain stated that he advanced the power for takeoff and that acceleration was normal. He called V₁ and removed his hand from the thrust lever knobs and placed it behind the levers. He called V_R, and the rotation was made smoothly and normally.

The first officer told the Safety Board that he felt the stall warning stickshaker activate on the control column as the airplane lifted off the runway. He said that after becoming airborne, he sensed a loss of performance and felt the airplane sinking. The captain told the Safety Board that when the airplane broke ground, the stickshaker remained on and the airplane began to sink back toward the runway. He said that the "first officer stated something to the effect of it's not flying or it won't fly, 'you've got it'." He turned control of the airplane over to the captain. The captain stated that he had a split second to decide either to continue to take off or to abort, when he probably would not be able to stop on the runway. He saw a considerable amount of runway remaining and chose to abort. The captain also stated that the airplane had the proper attitude and air speed but was not flying. He said he positively did not believe that the airplane would fly.

The captain stated that he closed the thrust levers and put the airplane back on the runway. He applied full reverse thrust and maximum braking. The airplane began to decelerate, but not as fast as he had expected. He said that the brakes seemed to be losing their effectiveness. He concluded that with approximately 1,500 feet of runway remaining and the air speed still about 100 knots, he would not be able to stop before reaching the blast fence at the end of the runway. He was able to maintain directional control throughout the landing. When it became apparent that he would not be able to stop before hitting the barrier at the end of the runway, he turned the airplane left off of the runway onto an open area covered with grass. Beyond the grass was concrete; he was sure he would be able to stop either on the grass or concrete.

The captain stated that a fire warning went off either before or after he turned off the runway. The flight engineer silenced the warning bell and the captain directed him to pull the appropriate handle and activate the extinguisher agent bottles.

The captain stated that he sensed a "sharp thump" about the time the airplane departed the runway. At the time, he was intent on maintaining directional control and stopping, but he knew later that the thump was the collapse of the nose wheel. Examination of the airplane revealed that the nose gear strut fractured so that it collapsed back and up, against the underside of the forward fuselage.

About the time the airplane came to a stop, the captain turned off the fuel and ignition switches, and directed the first officer to pull the handles on the other engines and activate their extinguisher agent bottles.

The captain stated that the evacuation alarm went off as the flight engineer was reaching to activate it. The captain got on the public address system (PA) and stated, "This is the captain, evacuate the aircraft." The captain entered the cabin to direct the evacuation.

The crew quickly evacuated all of the passengers through the most forward right and the two forward left cabin exits. The second cabin exit hatch on the right side was opened during the evacuation, but because smoke and fire were immediately outside the exit, it was quickly closed. The captain examined the cabin for any remaining passengers and was the last person to exit the airplane.

Pilots of other airplanes were part of the witness group. Some of them described the airplane as landing fast and far down the runway. A pilot of an airplane waiting on taxiway Lima Alpha, facing perpendicular to about the 8,500-foot mark on runway 13R, stated that he did not see anything abnormal about the airplane, other than an excessive rate of descent. He stated that the extremely hard landing caused a large puff of smoke to come from the main gear, with a great deal of strut compression and wing flex.

Some of the witnesses stated that they saw debris come from the underside of the airplane or a main wheel area about the time of touchdown. Other witnesses, most notably those in the JFK control tower, observed a similar sequence of events. However, some of the witnesses in the control tower stated that the first time they saw debris come from the airplane was about the time of rotation.

Witnesses had similar descriptions of the events that follow touchdown; they saw debris, smoke, or mist come from the airplane about the time of touchdown and following touchdown. The substance continued to come from the underside of the airplane or right wing area as the airplane continued down the runway. A large fireball developed on the outside of the fuselage. One witness described seeing the fireball travel aft and possibly enter the inlet of the No. 2 engine.

As indicated by tire marks on the runway and subsequent furrows the soil, the left main landing gear departed the left side of the runway about 11,350 feet from the runway threshold. The right main landing gear departed the left side of the runway about 13,250 feet from the threshold. There was also a blackened and burned streak on the runway, beginning about 12,650 feet from the threshold. The streak ran in conjunction with the tire marks off the left side of the runway. The burned streak continued to the point where the airplane came to rest. The airplane came to rest, upright and on fire, on grass-covered soil, about 296 feet to the left of the departure end of runway 13R, on a heading of about 100 degrees, approximately 14,368 feet from the threshold of the departure runway.

Within 2 minutes of the time the airplane came to rest, airport rescue and fire fighting (ARFF) trucks arrived at the site. However, the airplane continued to burn. Before the fire could be extinguished, it consumed the entire aft fuselalage in the area behind the wings and above the cabin floor. The fire also burned through the lower fuselage in two places, so that two sections fell separately to the ground, After the fire was extinguished, the airplane rested on the wheels from the two ma landing gear and the structure and skin beneath the forward cockpit and nos Figures 3 and 4 are photographs of the wreckage.

There were no fatalities. Of 280 passengers on board the airplane, there were 10 reported injuries that occurred during egress. Of the injuries, most were minor. There was one fractured leg. Of the 12 crewmembers, there were no reported injuries.

The accident occurred during daylight hours. The airplane came to rest at 40 degrees, 37.7 minutes north latitude, and 73 degrees, 46.3 minutes west longitude.

1.2 Injuries to Persons

Injuries	Flightcrew	Cabin Crew	Passengers*	Others	Total
Fatal	0	0	0	0	0
Serious	0	0	1	0	1
Minor	0	0	9	0	9
None	3	9	270	0	282
Total	3	9	280	0	292

• Includes two occupants of the cockpit jumpseats and five off-duty flight attendants.

The airplane was destroyed by fire. Its value was estimated at $12 to $13 million.

1.4 Other Damage

Damage to the runway and surrounding terrain was minimal. One runway edge light and two taxiway lights on the left side of the runway were destroyed. There was no estimate available regarding the cost of the damage to the runway and surrounding terrain.