General Mitchell International Airport
Aircraft Accident/Incident Report

Milwaukee, Wisconsin 53207
Monday, February 19, 2001 7:30 CST

NTSB Narrative Summary Released at Completion of Accident

A Boeing 717 sustained an in-flight thrust reverser deployment following a takeoff. The flight returned without further incident. After the prior flight the reverser was unlocked but not deployed. The flightcrew found the reverser unlock light during preflight. The crew could not clear the indication and contract maintenance was contacted to lock out the reverser. The contractor was not familiar and asked for the procedure to be faxed to him. The contractor used an incomplete set of procedures to lock out the reverser. Post incident inspection revealed the thrust reverser doors had over deployed. Four locking pins and their fork shaped locking triggers showed nicks and gouges on their mating surfaces. Subsequently Boeing revised their dispatch guide to include that maintenance would have to verify that "no more than one Thrust Reverser Proximity Sensor indicates Open" and that operators verify that the thrust reverser unlock indication is not present and red lockout pins are present on the inoperative reverser. Subsequent to the incident the overcenter links were redesigned. Boeing and the thrust reverser manufacturer issued service bulletins (SB) to retrofit the existing engines with the new link's design change, the link's associated hardware, and rub plates. Airplanes in production will incorporate the SB items as a production change. Boeing's SB 717-78-004 stated, "Operators have reported five instances of thrust reversers failing to deploy and ten instances of side beam gouging. Inspections revealed that gouging had occurred between the over center link bolts and side beam assembly. One recent event resulted in a relatively new thrust reverser having side beam gouging so deep, it required a doubler to restore airworthiness. Rohr Incorporated Service Bulletin R715.78-008 provides instructions to modify the thrust reverser actuation system. The purpose of modifying the thrust reverser actuation system is to minimize the possibility of gouging and inadvertent in-flight thrust reverser deployment procedures given in this service bulletin."

NTSB Probable Cause Narrative

The failure of the operator to provide complete and comprehensive thrust reverser lock-out maintenance procedures and guidance to the contract maintenance personnel resulting in a partial and inadequate securing of the faulty thrust reverser and a subsequent inadvertent deployment following takeoff. Contributing to the incident is the failure of the contract maintenance personnel to verify that the maintenance instructions received where complete, accurate, and up to date.

Event Information

Type of Event Incident
Event Date 2/19/2001
Event Day of the Week Monday
Time of Event 730
Event Time Zone Central Standard Time
Event City Milwaukee
Event State WISCONSIN
Event Country --
Zipcode of the event site 53207
Event Date Year 2001
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport GENERAL MITCHELL INTERNATIONAL
Event Location Nearest Airport ID MKE
Indicates whether the acc/inc occurred off or on an airport --
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 723
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 452 Central Standard Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID MKE
Elevation of weather observation facility 723
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation CST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 4900
Sky/Lowest/Cloud Conditions Few
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) -2
Dew Point at event time (in degress fahrenheit) -7
Wind Direction (degrees magnetic) 210
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 12
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 19
Altimeter Setting at event time (in. Hg) 29.91
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report MKE 19th day @ 1052Z 210/12G19 10sm vis few 4,
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 67
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 15061
NTSB Notification Source FAA
NTSB Notification Date Feb 21 2001 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Mar 30 2004 8:14AM
User who most recently changed record NTSB\MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office FAA-AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2410W
NTSB Number CHI01IA124
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Boeing
Aircraft Model 717-231
Aircraft Series Identifier --
Aircraft Serial Number 55077
Certified Max Gross Weight 118000
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 117
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Feb 17 2001 12:00AM
Airframe hours since last inspection --
Airframe Hours 770.3
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name First Security Bank NA Trustee
Aircraft Owner Street Address 79 S. Main Street
Aircraft Owner City Salt Lake City
Aircraft Owner State UT
Aircraft Owner Country USA
Aircraft Owner Zipcode 84111
Operator is an individual? No
Operator Name TRANS WORLD AIRLINES INC
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 11495 Natural Bridge Road
Operator City Bridgeton
Operator State MO
Operator Country USA
Operator Zip code 63044
Operator Code TWAA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code MKE
Departure City Milwaukee
Departure State WI
Departure Country USA
Departure Time 720
Departure Time Zone CST
Destination Same as Local Flt --
Destination Airport Code STL
Destination City ST LOUIS
Destination State MO
Destination Country USA
Specific Phase of Flight Takeoff
Report sent to ICAO? Yes
Evacuation occurred No
Date of most recent change to record Feb 18 2004 1:55PM
User who most recently changed record SULP
Since inspection or accident Time of Accident
Event Location Runway Number and Location 19R
Runway Length 9690
Runway Width 200
Sight Seeing flight No
Air Medical Flight No
Medical Flight --