Allegiant MD83 at Las Vegas on Aug 17th 2015, rejected takeoff due to premature rotation

Last Update: May 13, 2017 / 10:59:01 GMT/Zulu time

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Incident Facts

Date of incident
Aug 17, 2015

Classification
Incident

Flight number
G4-436

Aircraft Registration
N407NV

ICAO Type Designator
MD83

An Allegiant Airlines McDonnell Douglas MD-83, registration N407NV performing flight G4-436 from Las Vegas,NV to Peoria,IL (USA), was preparing for departure with a delay of almost 4 hours. The aircraft was accelerating for takeoff from runway 25R, when the nose wheel lifted off prematurely and without pilot input at about 120 KIAS. At that time tower cleared the next departure to maintain visual separation to the departing Allegiant MD83 and for takeoff from runway 25R, a few seconds later tower cancelled that takeoff clearance when the crew of the Allegiant MD-83 rejected takeoff at high speed, the nose gear touched down again and the aircraft slowed safely. The crew indicated that no assistance was needed and taxied to the apron.

The FAA reported: "The Federal Aviation Administration is investigating an incident that occurred on Aug. 17 when a McDonnell Douglas MD-83 operated Allegiant Airlines experienced a flight control problem while taking off from Las Vegas McCarran International Airport. The crew reported that the nose wheel lifted off of the runway prematurely during the takeoff roll. The captain discontinued the takeoff and returned safely to the gate. The airline reported the incident to the FAA. A preliminary investigation found that a nut on a component that moves the left elevator had fallen off, causing the control surface to become jammed in the up position."

The airline reported the left elevator boost actuator of N407NV had become disconnected. A fleet wide examination of MD-80 aircraft was conducted with no further anomaly found.

The NTSB told The Aviation Herald they are investigating the occurrence, subsequently amending the note to: "Or, more accurately, we are in contact with the company about the incident."

The rotation G4-436/G4-437 was cancelled.

The occurrence aircraft resumed service about 62 hours after the rejected takeoff.

On May 12th 2017 the FAA accidentally sent their unredacted investigation report to the Tampa Bay Times, however, without any photos mentioned in the file. The report states, that the maintenance service provider to Allegiant, AAR Aircraft Services Incorporated, had performed maintenance on the aircraft on May 23rd 2015 by installing an overhauled “left elevator boost control cylinder” Serial Number SRT001. Following the incident the FAA inspector verified, that the unit then installed on the aircraft and following the incident removed from the aircraft was the same that had been installed on May 23rd 2015. As part of that maintenance task it was also necessary to perform a weight and balance on the left hand elevator, "which required that the left elevator (and tabs) be removed and reinstalled, which was found to also affect the rod end for the elevator power control boost cylinder, as the castellated nut must be removed from the elevator power control boost cylinder rod end in order to remove the elevator."

The inspector further established: "The mechanic confirmed that the access panel that gives access to the elevator boost cylinder rod end nut is normally a sealed panel and was sealed prior to him opening it for access to the rod end. If a cotter pin had fallen out of the castellated nut due to being improperly installed it would have been retained in the immediate enclosed area. A castellated nut and washer that fell off the rod end were located but a cotter pin in that area was not found, this indicates a cotter pin had not been installed."

The investigation found: "when the nut and washer fell off, the rod end came out of the orifice, and the elevator rod end wedged on the structure. Pictures provided show evidence that the rod end had been loose withinthe rod end orifice, as was determined by the wear on the threads."

The investigation concluded that the elevator boost cylinder rod end nut had been incorrectly installed without being recorded as being incomplete and returned the aircraft to service contrary to requirements. This further led to non-inspection of these portions of the left elevator, that were required inspection items. This omission of inspection was identified as a causal factor into the serious incident.

The FAA analysed that the failure to document and perform maintenance steps violated both FAA regulations as well as AAR's own quality control manual.

The FAA described the legal fall out of the investigation: "Aircraft N407NV flew a total of 261 revenue flights (See IOP #26) before the nut backed off of the elevator power control boost cylinder rod end and caused the loss of pitch control that resulted in the aborted takeoff on August 17, 2015. Had the nut fallen off while the aircraft was actually flying, or had the crew not aborted the takeoff, the maintenance and inspection complacent actions performed by AAR Aircraft Services personnel would have resulted in an aircraft flying without the ability to control its pitch attitude, as evidenced by the aborted takeoff flight control response experienced by the crew on N407NV. Deliberate acts of noncompliance by company personnel resulted in improper maintenance that endangered numerous lives and properties during 261 subsequent flights following its return to service by AAR Aircraft Services, Inc., caused an unacceptable safety risk to safety and caused the airline to be in violation of 14 CFR. Part 121.369(b)(1)." Following the receipt of a response by AAR stating that the maintenance steps had been completed including the last steps 28 and 29, the FAA thundered: "This confirms that they are even now, still not familiar or do not intend follow the Allegiant Air GMM procedures for documenting Forms M301 and M302 specifically requires maintenance personnel to enter partial work to be entered in the Partial Work Accomplished sections of the form as indicated in GMM Page 21.2.19.1Section B items 4 and 5 (See IOP 21B), which the repair station is required to follow. Additionally, in the response from AAR Aircraft Services, Inc., on page 3 paragraph 2, they state and admit that they have had the same quality escape two other times. This shows these quality lapses are likely systemic, and yet the repair station shows angst over not being allowed to self-disclose a recurring concern."

The FAA continued to thunder: "There are deliberate and systemic acts of noncompliance with the airline procedures, repair station procedures and Federal Aviation Regulations by personnel at the AAR Aircraft Services, Inc., which indicates lack of management oversight. It is evident that the corrective actions plans to previous noncompliance events by the repair station overlook the complacency of management, complacency of Quality Assurance and acts of deliberate omissions by the maintenance technicians and the inspection department that are written off as human factor issues, instead of identifying them as deliberate actions of noncompliance with Federal Aviation Regulations, the Repair Station Quality Control Manual procedures and the airlines GMM procedures that company personnel must comply with for safety of the flying public. This shows lack of management oversight or training by AAR Aircraft Services and is shown to be an unacceptable risk."

The FAA concluded: "This violation was deliberate. While there was no mal intent by the company personnel it is evident that several deliberate and cognizant actions can be identified that were made by the maintenance technicians and the inspection personnel at AAR Aircraft Services, Inc., and includes a strong likelihood of lack of managerial oversight as is discussed below."

The FAA investigator thus made following recommendation: "I recommend maximum sanction be imposed for each FAR violation identified, in addition I recommend that a sanction be added for each of the 216 flights that were flown in violation as AAR Aircraft Services, Inc , was causal to the flights flown in an unairworthy condition."
Aircraft Registration Data
Registration mark
N407NV
Country of Registration
United States
Date of Registration
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Manufacturer
MCDONNELL DOUGLAS
Aircraft Model / Type
DC-9-83(MD-83)
Number of Seats
ICAO Aircraft Type
MD83
Year of Manufacture
Serial Number
Aircraft Address / Mode S Code (HEX)
Engine Count
Engine Manufacturer
Engine Model
Engine Type
Pounds of Thrust
Main Owner
Nig dejfngbAggmcpnlpiempjhkkpmfhbAhhepn hlcfqpmkndAmmdlkinegphjnnqdhpqdenpqhq Subscribe to unlock
Incident Facts

Date of incident
Aug 17, 2015

Classification
Incident

Flight number
G4-436

Aircraft Registration
N407NV

ICAO Type Designator
MD83

This article is published under license from Avherald.com. © of text by Avherald.com.
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