NTSB: Pilot Error Led to Crash of AA Flight 587

October 27, 2004

American Airlines flight 587 crashed into a Queens, New York neighborhood because the plane’s vertical stabilizer separated in flight as a result of aerodynamic loads that were created by the first officer’s unnecessary and excessive rudder pedal inputs after the aircraft encountered wake turbulence, according to a final report adopted by the National Transportation Safety Board this week. The Board said that contributing to the crash were characteristics of the airplane’s rudder system design and elements of the airline’s pilot training program.

At about 9:16 a.m. on Nov. 12, 2001, flight 587, an Airbus A300-605R (N14053), crashed in Belle Harbor, New York shortly after taking off from John F. Kennedy International Airport on a flight to Santo Domingo. All 260 people aboard the plane died, as did five persons on the ground, making the event the second deadliest aviation accident in American history.

The aircraft’s vertical stabilizer and rudder were found in Jamaica Bay, about a mile from the main wreckage site. The engines, which also separated from the aircraft seconds before ground impact, were found several blocks from the wreckage site.

The Safety Board found that the first officer, who was the flying pilot, inappropriately manipulated the rudder back and forth several times after the airplane encountered the wake vortex of a preceding Boeing 747 for the second time. The aerodynamic loads placed on the vertical stabilizer due to the sideslip that resulted from the rudder movements were beyond the ultimate design strength of the vertical stabilizer. (Simply stated, sideslip is a measure of the “sideways” motion of the airplane through the air.)

The Board found that the composite material used in constructing the vertical stabilizer was not a factor in the accident because the tail failed well beyond its certificated and design limits.

The Safety Board said that, although other pilots provided generally positive comments about the first officer’s abilities, two pilots noted incidents that reportedly showed that he had a tendency to overreact to wake turbulence encounters. His use of the rudder was not an appropriate response to the turbulence, which in itself provided no danger to the stability of the aircraft, the Board found.

The Board said that American Airlines’ Advanced Aircraft Maneuvering Program contributed to the accident by providing an unrealistic and exaggerated view of the effects of wake turbulence on heavy transport-category aircraft. In addition, the Board found that because of its high sensitivity, the A300-600 rudder control system is susceptible to potentially hazardous rudder pedal inputs at higher speeds.

In particular, the Board concluded that, before the crash of flight 587, pilots were not being adequately trained on what effect rudder pedal inputs have on the A300- 600 at high airspeeds, and how the airplane’s rudder travel limiter system operates.

The Safety Board’s airplane performance study showed that the high loads that eventually overstressed the vertical stabilizer were solely the result of the pilot’s rudder pedal inputs and were not associated with the wake turbulence. In fact, had the first officer stopped making inputs at any time before the vertical stabilizer failed, the natural stability of the aircraft would have reportedly returned the sideslip angle to near 0 degrees, and the accident would not have happened. (The Board estimated that the sideslip angle at the time the vertical stabilizer separated was between 10 and 12.5 degrees.)

The NTSB issued eight recommendations in the report. Among the seven sent to the Federal Aviation Administration were those calling for adopting certification standards for rudder pedal sensitivity, modifying the A300- 600 and A310 rudder control systems to increase protection from potentially hazardous rudder pedal inputs at high speeds (a similar recommendation was issued to the French equivalent of the FAA, the DGAC), and publishing guidance for airline pilot training programs to avoid the kind of negative training found in American Airlines’ upset recovery training.

Because this crash occurred two months after the Sept. 11 terrorist attacks, there was initial concern that it might have been the result of an intentional criminal act. The Board found no such evidence, nor did any law enforcement agencies provide evidence that the accident may have stemmed from criminal conduct.

The Board continued that witnesses who reported observing the airplane on fire were most likely observing misting fuel released from broken fuel lines, a fire from the initial release of fuel or the effects of engine compressor surges.

Editor’s note: A summary of the Board’s report may be found under “Publications” on the agency’s Web site at www.ntsb.gov. A number of lawsuits were filed by families of those killed in the accident, alleging American was responsible for the crash by failing to properly maintain and inspect the Airbus 300. The lawsuits also charged the airline failed to properly train workers involved in the inspection, maintenance and operation of the aircraft.

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