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Aviation safety reports, made easier to study

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July 10, 1993 · Mcdonnell Douglas DC-10-40 · N158US

Detroit, MI

Overview

Report Status
Final with probable cause
Event Type
Incident
Date
July 10, 1993
Injury Outcomes
No injuries (103 uninjured)
Location
Detroit, MI
Aircraft
Mcdonnell Douglas DC-10-40
Tail Number
N158US
Injuries
None
NTSB Number
CHI93IA248

WHILE CLIMBING THROUGH 20,000 FEET THE #1 INS FAILED. THE GYRO OUTPUT VARIED AS THE GYRO TUMBLED, WHICH PRODUCED A BANK ANGLE SIGNAL. THE FAILURE MODE ALLOWED THE BANK ANGLE INFORMATION TO BE TRANSMITTED TO THE YAW FLIGHT GUIDANCE COMPUTER, ALLOWING THE ATTITUDE MONITORING AND SWITCHING UNIT TO MOVE THE LOWER RUDDER HYDRAULIC ACTUATOR, CAUSING THE LOWER RUDDER TO MOVE.

NTSB Probable Cause

the failure of a navigation system (#1 INS) for reason or reasons undetermined.

Full Narrative

On July 10, 1993, about 1900 eastern daylight time, a McDonnell Douglas DC-10-40, N158US, registered to and operated by Northwest Airlines, Inc., as Flight 48, experienced an uncommanded rudder oscillation while climbing through 20,000 feet (mean sea level). The anomaly was corrected when the crew disconnected the number one inertial navigation system (INS). The airplane returned to Detroit, Michigan, where it landed without incident. The flight crew of three, cabin crew of eight, and 92 passengers reported no injuries. The airplane sustained no damage. The 14 CFR Part 121 flight was a domestic flight operating between Detroit, Michigan, and Boston, Massachusetts. The flight was on an IFR flight plan; however, VFR conditions existed at Detroit, Michigan. The flight departed at 1842 and returned at 1930. The airplane was examined by the NTSB, FAA, and Northwest Airlines personnel in Detroit on July 11, 1993. The #1 INS display unit and the Captain's attitude indicator were replaced. The cockpit voice recorder (CVR) and flight data recorder (FDR) were removed and taken to the NTSB laboratories in Washington, DC for readout. A review of the airplane's design indicated that the #1 INS provides bank angle information to the yaw flight guidance computer through the attitude monitoring and switching unit. The bank angle information is then transmitted from the yaw flight guidance computer to the lower rudder hydraulic actuator to move the rudder. On July 11, 1993, while the airplane was at Northwest maintenance facilities in Detroit, MI, the examination of the #1 INS began with a cockpit test to identify fault codes recorded in the INS. Fault codes were recorded consistent with a #1 INS failure. The #2 INS and standby INS were examined and both appeared to be operational. The airplane's hydraulic systems were powered via the APU. All flight controls were operated with no anomalies. The yaw damper system self-test was completed with no anomalies. Following the tests and examinations, the #1 INS and controller were removed along with the Captain's ADI. These components were sent to Northwest Airlines facilities for further evaluation. Following a preflight inspection, the airplane was flight tested by Northwest Airlines flight crew. The flight test involved extensive maneuvering of the airplane and a thorough operation of all flight control systems and INS operations. The flight was accomplished successfully. On or about July 16, 1993, bench testing of the #1 INS, by Northwest personnel, indicated that the internal gyro generating bank-axis (lateral) reference information had failed. The gyro output varied as the gyro tumbled, which produced a bank angle signal. The INS warning light that illuminated on the unit during the incident event correctly identified a failure of the unit. Northwest Airlines personnel reported that testing verified there were no anomalies with the Captain's ADI. The Digital Flight Data Recorder Factual Report is attached as an addendum to this report.

Flight

Event TypeIncident
Event Time19:00 EDT
Nearest Airport0nm
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftMcdonnell Douglas DC-10-40
Tail NumberN158US
Aircraft CategoryAir
Operating RulePart 121
Engines3
Engine TypeTurbofan
Engine DetailsP&W · JT9D-20J · Turbofan · 40000
Seats294

People & Injuries

Injury SummaryNo injuries (103 uninjured)
Fatal0
Serious0
Minor0
Uninjured103
Total103
Crew 1Age 52 · First Class

Conditions

ConditionsVMC
LightDaylight
Wind240° @ 10 kt
Visibility20 sm
CeilingNone
Altimeter30.00 inHg
Observation Time22:53
Weather SourceWFAC

Appendix: Source Data