Pilot Debrief

EMBRAER EMB-145 near Chicago, IL — 2011-06-03

Final reportCEN11IA369
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Date
2011-06-03
Location
Chicago, IL, USA
Airport
ORD
Aircraft
EMBRAER EMB-145
Registration
N607AE
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The overheat and failure the brake during landing due to oxidation of the brake rotors, which went undetected by maintenance personnel. Contributing to the accident was maintenance personnel’s lack of familiarity with detailed brake oxidation inspection procedures.

Contributing factors

Contributing to the accident was maintenance personnel’s lack of familiarity with detailed brake oxidation inspection procedures.

NTSB narrative

The pilots reported that they felt one brake pedal fully release and then reapply during the landing roll. Air traffic control tower personnel saw a puff of smoke and asked the flight crew if a tire had blown on landing. The pilots taxied the airplane to a hold pad for further examination; however, the emergency brake would not hold the airplane stationary. The pilots also received caution messages for the brakes, and hydraulic fluid was observed on the tires and ground. An examination revealed the brake pressure plate and rotor failed. Separated brake parts were also found on the landing runway. Further examination of the incident brake and four other brakes revealed that they all contained varying levels of oxidation development. The brake manufacturer had previously provided the operator with a maintenance procedure which involved using a fingernail or a specified plastic tool to check brakes for oxidation. The operator developed and provided related training to its maintenance personnel based on the manufacturer's procedures. However, interviews with airline and contract maintenance personnel revealed that they were not familiar with the inspection and were not issued the plastic tool. Subsequently, the brake manufacturer and operator provided additional related training to the operator's maintenance personnel, and the operator stocked their maintenance system with the specified tool.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Proper brake inspection procedures were not followed prior to the incident.

NTSB coding

  • Sys/Comp malf/fail (non-power) · Landing-landing roll

Evidence available

  • FDR / data
  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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