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142 ICAO C i r c u l a r 8&AN/74

V a r i g A i r l i n e s , DC-8, PP-PEA, a c c i d e n t a t R o b e r t s I n t e r n a t i o n a l A i r p o r t ,
C h a r l e s v i l l e , M a r s h a l l T e r r i t o r y . L i b e r i a , on 5 March 1967. Summary of
A i r c r a f t Accident Report d a t e d 1 3 September 1967, r e l e a s e d by t h e
Commission of I n q u i r y , Department of Commerce and I n d u s t r y ,
R e p u b l i c of L i b e r i a

1. - Investigation

1.1 H i s t o r y of t h e f l i g h t

F l i g h t R 6 837 d e p a r t e d ~ o m e / F i u m i c i n oA i r p o r t , I t a l y , a t 2108 h o u r s GMT on


4 March 1967, on a scheduled i n t e r n a t i o n a l f l i g h t f o r ~ o n r o v i a / R o b e r t s , L i b e r i a .

The f l i g h t was u n e v e n t f u l u n t i l t h e a i r c r a f t came overhead t h e R o b e r t s VOR


a t FL 45 a t 0249 h o u r s GMT on 5 March 1967. The a i r c r a f t d i d n o t e n c o u n t e r any s i g n i f i c a n t
w e a t h e r d u r i n g c l i m b t o and c r u i s i n g on t h e c l e a r e d c r u i s i n g f l i g h t l e v e l s 310 and 350 nor
on i t s i n i t i a l d e s c e n t t o overhead R o b e r t s VOR. A t no t i m e was t h e r e any r e p o r t e d mal-
f u n c t i o n i n g of t h e e n g i n e s o r a i r c r a f t systems. Normal p o s i t i o n r e p o r t s were p a s s e d a t t h e
a p p r o p r i a t e t i m e s o v e r t h e mandatory r e p o r t i n g p o i n t s e n r o u t e .

A d e s c e n t under v i s u a l m e t e o r o l o g i c a l c o n d i t i o n s a t 300 k t IAS a t an a v e r a g e


r a t e of d e s c e n t of about 2 000 f t p e r minute w a s c a r r i e d o u t from FL 350 from a r a n g e of
90 t o 95 miles on t h e R o b e r t s A i r p o r t DME a t 0234 h o u r s GMT a p p r o x i m a t e l y . A t 0247:48 h o u r s ,
t h e a i r c r a f t r e p o r t e d i t s p o s i t i o n as 5 m i l e s o u t a t FL 45 when ATC f o r t h e second time
p a s s e d t h e 0200 QNH of 1 009 mb, w i t h a f u r t h e r d e s c e n t c l e a r a n c e t o 3 000 f t on t h e VOR.
The QNH w a s r e a d back c o r r e c t l y and t h e pilot-in-command and c o - p i l o t confirmed t h a t t h e i r
a l t i m e t e r s were c r o s s checked a t FL 45. No r e f e r e n c e was made by t h e crew of t h e f u r t h e r
d e s c e n t c l e a r a n c e £row FL 45 t o 3 000 f t and t h e pilot-in-command d i d n o t descend t o t h e
c l e a r e d a l t i t u d e b u t m a i n t a i n e d FL 45 overhead t h e VOR. During t h e d e s c e n t and t h e approach,
t h e pilot-in-command conducted t h e f l i g h t f r o m . t h e l e f t - h a n d s e a t , w i t h t h e e o - p i l o t i n
t h e r i g h t - h a n d s e a t and t h e second o f f i c e r occupying t h e jump s e a t behind t h e p i l o t - i n -
command.

A f t e r s i g h t i n g t h e aerodrome runway l i g h t s from v e r t i c a l l y overhead, t h e


pilot-in-command informed t h e c o - p i l o t t h a t d e s p i t e t h e f a c t t h a t he had t h e runway com-
p l e t e l y i n s i g h t h e would make a n IFR/VOR p r o c e d u r e . A V O ~ / L o c a t o r i n s t r u m e n t let-down was
commenced from 4 500 f t ONH o v e r t h e VOR a t a n i n d i c a t e d a i r s p e e d of 210 slowing t o 170 k t ,
d e s c e n d i n g a t a r a t e of between 500 t o 700 f t p e r minute u n t i l t h e a i r c r a f t a r r i v e d a t a
p o i n t inbound o v e r t h e c o a s t l i n e ( s e e F i g u r e 1 ) a t 1 800 i t QNH on a h e a d i n g of 047O M, g e a r
down, 350 f l a p s f o r l a n d i n g on runway 04. A t t h i s p o i n t t h e c o - p i l o t r e p o r t e d : "Runway i n
s i g h t a l i t t l e t o t h e l e f t " and s t a t e d : II I saw t h e runway a g a i n o b s e r v i n g t h e runway l i g h t s
II
and t h e VASI l i g h t s c o m p l e t e l y white". He a l s o r e p o r t e d i n f o r m i n g t h e ATC: Runway i n
s i g h t and b o t h VASI showing white" a l t h o u g h t h i s was n o t confirmed by t h e ATCO. (A f l i g h t
test carried ouf d u r i n g the i n v e s t i g a t i o n showed t h a t t h e minimum a l t i t u d e a t t h i s p o i n t t o
see t h e VASI l i g h t s a l l w h i t e is 1 800 i t . ) The pilot-in-command s t a t e d t h a t a t t h i s time:
"I looked o u t s i d e and saw p a r t of t h e a i r p o r t l i g h t s because t h e v e r y b e g i n n i n g of t h e
runway I c o u l d n o t see b e c a u s e of a bunch of c l o u d s on my s i d e view. 11
ICAO C i r c u l a r 8 8 - ~ N / 7 4 - -.- --143
-

During t h e approach f r o m t h e c o a s t t o t h e a i r p o r t , t h e pilot-in-command d i d


not make any u s e of t h e DME w i t h which the a i r p u r t and t h e a i r c r a f t were p r o v i d e d . He
s t a t e d t h a t h e d i d not u s e i t because h e itad tile c o a s t l i n e i n d i c a t e d by r a d a r .

A f t e r t h e p r o c e d u r e t u r n , t h e a i r c r a f t was on t h e c o r r e c t VOR r a d i a l and a


smooth approach was c a r r i e d out d u r i n g which t h e a i r c r a f t was flown manuallv. The p i l o t -
in-command i n s t r u c t e d t h e c o - p i l o t and t h e second o f f i c e r s t o l o o k o u t s i d e . Though t h e
s t a t e m e n t s of t h e pilot-in-command and t h e c o - p i l o t were n o t always c o i n c i d e n t i n r e s p e c t
t o t h e s p e e d s of t h e a i r c r a f t , i t i s l i k e l y t h a t i n t h e p r o c e d u r e t u r n t h e s p e e d was
reduced t o about 140 k t ( t h r e s h o l d speed was c a l c u l a t e d t o be 1 3 1 k t ) and t h a t t h i s s p e e d
remained b a s i c a l l y c o n s t a n t t h r o u g h o u t t h e f i n a l approach.

A f t e r t h e p r o c e d u r e t u r n , t h e c o - p i l o t c a l l e d e a c h 100 i t of a l t i t u d e and t h e
speed and he checked t h e i n d i c a t i o n of t h e v e r t i c a l speed i n d i c a t o r s . A t a n a l t i t u d e o f
about 1 000 i t , f l a p s were p u t i n t h e f u l l down p o s i t i o n and s h o r t l y t h e r e a f t e r , a t a n
a l t i t u d e of 800-700 f t , t h e a i r c r a f t e n t e r e d some s t r a t u s and, f u r t h e r down, f o g p a t c h e s .
When e n t e r i n g t h e s t r a t u s l a y e r , t h e pilot-in-command t o l d t h e co-pi10.t t h a t i t was no
l o n g e r n e c e s s a r y t o r e p o r t a l t i t u d e and speed and was i n s t r u c t e d t o l o o k o u t s i d e and t o
r e p o r t a s s o o n a s he c o u l d s e e t h e runway. According t o t h e c o - p i l o t , t h i s i n s t r u c t i o n
was g i v e n when t h e a i r c r a f t was p a s s i n g overhead t h e FR l o c a t o r beacon.

The pilot-in-command o b s e r v e d t h a t h i s a l t i t u d e over FR was a b o u t 800 i t ,


It
whereas h i s c o r r e c t a l t i t u d e s h o u l d have been 520 i t . H e t o l d t h e c o - p i l o t : I am a
l i t t l e h i g h and I am d e s c e n d i n g t o 550 i t " and i n s t r u c t e d him t o l o o k o u t s i d e f o r t h e run-
way, which was e x p e c t e d t o b e s e e n a t any t i m e , as t h e v i s i b i l i t y a c c o r d i n g t o t h e w e a t h e r
r e p o r t was 10 km. H e t h e n i n c r e a s e d h i s r a t e of d e s c e n t t o between 1 200-1 500 f t / m i n ,
by r e d u c t i o n of power and by p i t c h i n g t h e n o s e of t h e a i r c r a f t down. About 1 5 s e c o n d s
a f t e r p a s s i n g FR t h e c o - p i l o t r e p o r t e d runway i n s i g h t , s a y i n g a l s o t h a t t h e v i s i b i l i t y
was poor and t h a t t h e y were t o o low. T h i s l a s t i n f o r m a t i o n was based on t h e f a c t t h a t h e
saw b o t h VASI l i g h t s r e d , b u t h e d i d n o t mention t h i s t o t h e pilot-in-command.

During t h e f i n a l phase of t h e f l i g h t , t h e second o f f i c e r made s e v e r a l observa-


t i o n s . The p e r t i n e n t e x t r a c t s from h i s s t a t e m e n t s , n o t n e c e s s a r i l y i n s e q u e n c e , a r e a s
follows :
11
... when I saw t h e approach was b e g i n n i n g t o become c r i t i c a l I looked
a t t h e altimeter and remarked t h a t i t was s t i l l above 500 i t . "
II
... a few moments l a t e r I saw t h e l i g h t s t h a t I suppose were of t h e
VASI due t o t h e i r i n t e n s i t y , a l i t t l e t o t h e l e f t of t h e a i r c r a f t . I
want t o make i t c l e a r t h a t t h e l i g h t s were o n l y a shade. A f t e r t h e s e
l i g h t s d i s a p p e a r e d I f e l t t h e a i r c r a f t s i n k i n g . Immediately I looked
a t t h e a l t i m e t e r and n o t i c e d t h e p o i n t e r p a s s e d 300 i t i n a f a s t
d e s c e n t and immediately a f t e r t h e a c c i d e n t o c c u r r e d . 11
It
... I
d i d n o t have time t o warn. I remember s l i g h t l y t h a t i t must
have h i t f o r t h e f i r s t t i m e more o r l e s s below 100 f t . "

The pilot-in-command s t a t e d t h a t t h e a i r c r a f t and i t s s y s t e m s , i n c l u d i n g t h e


a l t i m e t e r , had f u n c t i o n e d p r o p e r l v up u n t i l t h e time of impact.
144 ICAO C i r c u l a r 88-AN174

The f i r s t p o i n t of impact w a s a t a n e l e v a t i o n of 42 f t MISI,, 6 0 ' t r , rlln


t h e t h r e s h o l d of runway 0 ' + , 1 8 0 f t t o t h e r i g h t of t h e runway e x t e n d e d c e n t r e l i n e w i t h
t h e a i r c r a f t coming t o r e s t a £ ter a ground s l i d e of a p p r o x i m a t e l y T'jO f t t h e g-.-)und s l i d e
b e i n g p a r a l l e l t o t h e e x t e n d e d c e n t r e l i n e of runway 04.

The a i r c r a f t p a s s e d over power l i n e s which r u n n e a r l y p e r p e n d i c u l a r t n


c e n t r e l i n e of t h e runway, 440 f t b e f o r e t h e f i r s t p o i n t of impact w i t h t h e grt .
power l i n e s remained undamaged; t h e i r I i e i g h t i s 34 f t 2 i n above ground l e v e l ,.
2 i n AMSL). The a n g l e between t h e f i r s t p o i n t of impact and the top of t h e power l i n c ,
was found t o b e 4.50. Based on t h e above i t w a s c a l c u l a t e d t h a t t h e r a t e of d e s c e n t i n
t h e l a s t two s e c o n d s of t h e a p p r o a c h c o u l d n o t h a v e been less t h a n 1 1 5 0 f t ftlmin. The
a c c i d e n t o c c u r r e d a t n i ~ b fa t 0256 h o u r s CMT.

1.2 In-juries t o persons

None 2 14
.I i

* The f l i g h t e n g i n e e r d i d n o t s u r v i v e ,

1.3 Damage t o a i r c r a f t

The a i r c r a f t , w i t h t h e e x c e p t i o n of t h e t a i l assembly which w a s s u b s t a n t i a l l y


damaged, was d e s t r o y e d by ground impact and f i r e .

O t h e r damage

Five o t h e r p e r s o n s on t h e ground were fatally i n j u r e d , two h o u s e s were com-


p l e t e l y d e s t r o y e d and two o t h e r s s e v e r e l y damaged,

1.5 Crew information

The crew of 1 9 c o n s i s t e d of a pilot-in-command, co-pilot, second o f f i c e r ,


f l i g h t engineer, n a v i g a t o r l f l i g h t r a d i o o p e r a t o r , seven stewards, t h r e e stewardesses with
an a d d i t i o n a l f o u r s u p e r n u m e r a r y crew members who had no o p e r a t i o n a l d u t i e s .

The pilot-in-command, aged 45, h e l d n v a l i d a i r l i n e t r a n s p o r t n i l o t ' s l i c e n c e


w i t h a v a l i d t y p e and i n s t r u m e n t r a t i n g f o r DC-8. H i s t o t a l f l v i n g e x p e r i e n c e a t t h e time
of t h e a c c i d e n t was 1 7 718 h o u r s i n c l u d i n g 1 787 h o u r s i n command of t h e DC-8. He had
flown t h e same scheduLed i n t e r n a t i o n a l f l i g h t t h r e e t i m e s d u r i n g t h e s i x monttls p r e c e d i n g
t h e aczident . FTe s a t i s f a c t o r i l v Tqsaeii his 1st Dilr v e t l i c a l exr;min;tt i o n 0x1 2 h rtztril>er 1 9 6 6 ,
r ~ i t h o u tr e s t r ictions. In the 90 d a y s i m e d i c ? . t e l y precc ing t h e a c c i d e n t , he had f lown
107 h o u r s and enloved 3 d a y s ' r e s t i n Rone p r i o r t o take-off.
ICAO C i r c u l a r 88-Mi/ 74 145

The c o - p i l o t , aged 41, h e l d a v a l i d a i r l i n e t r a n s p o r t p i l o t ' s l i c e n c e w i t h


n v a l i d t v p e and i n s t r u m e n t r a t i n g a s c o - p i l o t on DC-8. H i s T o t a l flying experience at
t h e time of t h e a c c i d e n t was 1 5 911 hours i n c l u d i n g 408 h o u r s a s c o - p i l o t on t h e DC-8. He
s a t i s f a c t o r i l y passed h i s l a s t DAC medical e x a m i n a t i o n on 3 November 1966, w i t h o u t r e s t r i c -
tions. In t h e 90 days immediately p r e c e d i n g t h e a c c i d e n t , he had flown 150 h o u r s and
~:njoved 3 d a y s ' r e s t i n Rome p r i o r t o t a k e - o f f .

The second o f f i c e r , aged 33, h e l d a v a l i d commercial p i l o t ' s l i c e n c e w i t h no


i n s t r u m e n t r a t i n g w i t h c l a s s and t y p e r a t i n g f o r a e r o p l a n e s i n g l e e n g i n e l a n d Group A.
H i s t o t a l f l y i n g e x p e r i e n c e a t t h e t i m e of t h e a c c i d e n t w a s 8 0 6 7 , h o u r s i n c l u d i n g 1 818 h o u r s
a s second o f f i c e r on t h e DC-8. He a l s o h e l d a n e x p i r e d f l i g h t e n g i n e e r ' s l i c e n c e r a t e d
f o r t h e DC-8. He s a t i s f a c t o r i l y p a s s e d h i s last DAC m e d i c a l e x a m i n a t i o n on 1 5 J u n e 1966,
without r e s t r i c t i o n s . I n t h e 90 days immediately p r e c e d i n g t h e a c c i d e n t , h e had flown
2 2 3 h o u r s and enjoyed 3 d a y s ' rest i n Rome p r i o r t o t a k e - o f f .

The f l i g h t e n g i n e e r , aged 62, h e l d a v a l i d f l i g h t e n g i n e e r ' s l i c e n c e r a t e d


a s competent on DC-8 equipment. A t t h e t i m e of t h e a c c i d e n t h e had accumulated 1 1 5 1 h o u r s
of f l i g h t t i m e a s f l i g h t e n g i n e e r , of which 1 106 h o u r s were on t h e DC-8. H e a l s o held a
commercial p i l o t ' s l i c e n c e w i t h t y p e r a t i n g f o r a e r o p l a n e s i n g l e e n g i n e l a n d Group A. He
s a t i s f a c t o r i l y p a s s e d h i s l a s t DAC m e d i c a l e>.rlmination on 26 October 1966, w i t h o u t r e s t r i c -
tions. I n t h e 30 days immediately p r e c e d i n g t h e a c c i d e n t , h e had flown 40 h o u r s and
enjoyed 3 days' r e s t i n Rome p r i o r t o t a k e - o f f .

The n a v i g a t o r l f l i g h t r a d i o o p e r a t o r , aged 39, h e l d a v a l i d n a v i g a t o r l ' s and


f l i g h t r a d i o o p e r a t o r ' s l i c e n c e r a t e d a s n a v i g a t o r on DC-8 equipment. He satisfactorily
passed h i s l a s t DAC m e d i c a l e x a m i n a t i o n 9n 3 1 May 1966. I n t h e 30 d a y s immediately pre-
c e d i n g t h e a c c i d e n t , h e had flown 83 h o u r s 37 m i n u t e s .

1.6 Aircraft information

The a i r c r a f t ' s c e r t i f i c a t e of a i r w o r t h i n e s s , i s s u e d by t h e B r a z i l i a n C i v i l
A v i a t i o n a u t h o r i t i e s was v a l i d u n t i l 20 August 1967. The a i r c r a f t had been m a i n t a i n e d i n
a c c o r d a n c e w i t h Varig A i r l i n e s ' p r o c e d u r e s and t h e B r a z i l i a n C i v i l A v i a t i o n a u t h o r i t y
d i r e c t i v e s . It had accumulated a t o t a l of 16 775 h o u r s .

The c e n t r e of g r a v i t y was w i t h i n t h e p r e s c r i b e d l i m i t s .

1.7 Meteorological information

Approximately 20 m i n u t e s b e f o r e t h e t i m e of t h e a c c i d e n t , R o b e r t s Approach
C o n t r o l p a s s e d t h e f o l l o w i n g weather r e p o r t t o t h e a i r c r a f t f o r l a n d i n g . T h i s w a s t h e
0200 h o u r s a c t u a l :

S u r f a c e wind: calm
V i s i b i l i t y : 8 km ( 5 s t a t u t e m i l e s )
Weather: hazy
Cloud: 218 Sc 1 200 f t
Temperature: 240C
Dew-point: 23O~
QNH: 1 009.1 mb
QFE: 1 008.3 mb

Remarks: P a t c h e s of fog t o t h e n o r t h . Ceiling unlimited. Transition


l e v e l 45.
146 ICAO C i r c u l a r 88-AN17 4

The a c t u a l weather a t t h e t i m e of t h e a c c i d e n t ( t h i s w a s t h e 0300 hours


weather r e p o r t t a k e n between 0245 h o u r s and 0250 h o u r s ) w a s :

S u r f a c e wind: 050°/2 k t
V i s i b i l i t y : 8 km ( 5 s t a t u t e m i l e s )
Weather: l i g h t f o g ; 3 / 8 k S t 400 f t ; 2 / 8 k S t 1 200 f t
Temperatuie: 240C
Dew-point: 230C
QNH: 1 008.8 mb
QFE: 1 008.0 mb

Remarks: Ceiling unlimited. T r a n s i t i o n l e v e l 45.

It was n o t e d t h a t t h e m e t e o r o l o g i c a l o b s e r v e r a t R o b e r t s h a s no n i g h t v i s u a l
r e f e r e n c e p o i n t beyond t h e Z marker which is l o c a t e d 1 150 m (3 772 f t ) from t h e t h r e s h o l d
of runway 04 and 3.15 km (1.97 s t a t u t e m i l e s ) from t h e Met o b s e r v e r and t h e Duty ATCO.

The weather c o n d i t i o n s a t t h e a l t e r n a t e aerodromes b e f o r e and a t t h e t i m e of


t h e a c c i d e n t from o b s e r v a t i o n s a t Dakar, Abidjan and Conakry i n c l u d e d i n t h e Dakar HF/RT
Volmet b r o a d c a s t a l l i n d i c a t e d 8 t o 10 km ( 5 t o 6& s t a t u t e m i l e s ) and no s i g n i f i c a n t c l o u d s .

1.8 Aids t o n a v i g a t i o n

The f o l l o w i n g a i d s were a v a i l a b l e : VOR, DME, L o c a t o r NDB, Main NDB,


Z-Marker .
Runway 04 i s s e r v e d by a VASI i n s t a l l a t i o n d e s i g n e d t o p r o v i d e by v i s u a l
r e f e r e n c e t h e same i n f o r m a t i o n t h a t t h e g l i d e s l o p e u n i t of a n I L S p r o v i d e s e l e c t r o n i c a l l y .

An aerodrome beacon a l t e r n a t i n g G r e e d W h i t e i s s i t e d 2 000 i t e a s t of t h e


aerodrome.

1.9 Cormrmnicat i o n s

A l l communications w i t h t h e a i r c r a f t were normal. No a u t o m a t i c r e c o r d i n g


equipment i s i n s t a l l e d a t R o b e r t s and no r e c o r d of r a d i o t e l e p h o n y i s k e p t .

1.10 Aerodrome and ground f a c i l i t i e s

Runway 04, 9 000 f t long and 150 f t wide, i s equipped w i t h medium i n t e n s i t y


w h i t e runway l i g h t s and l e a d i n approach l i g h t s of low i n t e n s i t y , v a r i a b l e b r i l l i a n c y Amber
i n c a n d e s c e n t c e n t r e l i n e l i g h t s p l a c e d a t 1 0 0 - f t i n t e r v a l s e x t e n d i n g 1 400 f t from t h e
t h r e s h o l d w i t h Amber c r o s s - b a r l o c a t e d a t 1 000 f t from t h e runway t h r e s h o l d and a r e d
t h r e s h o l d runway b a r l o c a t e d 150 f t from t h e runway t h r e s h o l d .

1.11 F l i g h t r e c o r d e r s

The f l i g h t r e c o r d e r which was :-. -~.,.:r.xl from i t s h o u s i n g i n t h e f u s e l a g e


under t h e t a i l assembly had s u s t a i n e d danxo.. d u r i n g impact. E x a m i n a t i o n o f t h e r e c o r d i n g
medium c a r r i e d o u t a t t h e U.S. C i v i l A e r o n a u t i c s Board, F l i g h t Record L a b o r a t o r y , Washington,
r e v e a l e d no r e c o r d i n g s on t h e a c c i d e n t r e c o r d i n g medium. F u r t h e r examination r e v e a l e d t h a t
a r e d p l a s t i c t y p e m a t e r i a l had been i n s t a l l e d on t h e f a c e of t h e p l a t e n a s a s u b s t i t u t e
r e p l a c e m e n t f o r t h e t e f l o n m a t e r i a l nor:-!:>'ly used and recommended by t h e manufacturer.
I C A O C i r c u l a r 88-A':/ 74 147
- -

T h e s ~ i b s t i t u t fm a t e r i a l .was found t o have been foldetl on t h e f a c e of t h e p l a t e n , which


r e s u l t e d i n a r i d g e b e i n g formed t h a t p r e c l u d e d proDcr s c r i b i n i . of t h e p a r a m e t e r s t y l i on
t h e medium.

1.1 A i r c r a f t wreckage

The f i r s t p o i n t of impact showed t h e i m p r i n t of b o t h main l a n d i n g g e a r s and


t h e nose wheel. These i m p r i n t s c o n t i n u e d f o r a d i s t a n c e of 36 f t i n d i c a t i n g down and l o c k e d
position. T h e r e a f t e r , t h e u n d e r c a r r i a g e f a i l e d due t o t h e r i s h t main g e a r e n t e r i n g a h o l e .
A l l f l i g h t c o n t r o l s u r f a c e s and a l l major components of a l l a i r c r a f t s y s t e m s w e r e found i n
t h e vreckage a r e a , i n d i c a t i n g no e v i d e n c e of i n - f l i g h t s e p a r a t i o n of t h e a i r c r a f t s t r u c t u r e
o r components. I n i t i a l impact was a t a s t a b i l i z e r s e t t i n g of 40 t o 50 nose-up. Examination
of t h e empennage c o n t r o l s and a l l f o u r e n g i n e s r e v e a l e d no m a l f u n c t i o n . A l l f l i g h t and
e n g i n e s i n s t r u m e n t s , r a d i o s and n a v i g a t i o n a l r e c e i v e r s were e i t h e r damaged s e v e r e l y o r
d e s t r o y e d by impact f o r c e s a n d / o r by f i r e .

1.13 -
Fire

The a i r c r a f t caught f i r e e x t e r n a l l y d u r i n g i t s ground s l i d e w i t h t h e f i r e


e n t e r i n g t h e f u s e l a g e t h r o u g h a n overhead w i ~ , , ;emergency e x i t which came open a l m o s t com-
p l e t e l y d i v i d i n g t h e c a b i n a t row 15. The f i r e p r o g r e s s e d more r a p i d l y toward t h e rear of
t h e a i r c r a f t than the front.

Two c r a s h t r u c k s and one r e s e r v e w a t e r t e n d e r , manned by a t o t a l crew of


f i v e who were engaged i n f i g h t i n g t h e f i r e on each s i d e of t h e n o s e s e c t i o n were u n a b l e t o
t a k e r e s c u e a c t i o n i n t h e a r e a behind tile wing.

1.14 Survival aspects

W i t h i n t h e f u s e l a g e , t h e forward l i f e r a f t compartment d o o r opened and


p a r t i a l l y o b s t r u c t e d t h e forward l e f t - h a n d door. I n a d d i t i o n , t h e c o n t e n t s of t h e f o r w a r d
g a l l e y were a l l o v e r t h e f l o o r i n d i c a t i n g t h a t t h e g a l l e y d o o r s opened. P a g s e n g e r s from
s e a t row 13 i n t h e coach s e c t i o n and t h o s e i n t h e f i r s t c l a s s s e c t i o n e s c a p e d t h r o u g h t h e
forward l e f t - h a n d p a s s e n g e r door. The forward r i g h t - h a n d p a s s e n g e r d o o r w a s n e v e r opened.
I n t h e a f t c a b i n , t h e forward l i f e r a f t compartment door came ope0 and p e r m i t t e d t h e l i f e
r a f t t o f a l l t o t h e f l o o r h i t t i n g a crew member i n seat 28D. The c l o s e t , j u s t forward of
t h e r i g h t - h a n d c o a t room, b r o k e l o o s e and f e l l a c r o s s t h e aisle. The crew f o l d i n g seat
a d j a c e n t t o t h e l e f t a f t p a s s e n g e r door broke and dropped t h e two a t t e n d a n t s occupying t h e
s e a t t o t h e f l o o r , o b s t r u c t i n g t h e a c c e s s way t o t h e door. The seat b e l t s on t h i s seat
d i d n o t b r e a k ; however, s e a t b e l t s d i d b r e a k a t seats 2C and 25B.

I n t h e f r o n t s e c t i o n from seat row 1 3 f o r w a r d , t h e r e were 1 7 p a s s e n g e r s and


14 crew members. Eleven p a s s e n g e r s and 11 crpw members escaped t h r o u g h t h e f r o n t p a s s e n g e r .
door, l e f t s i d e . The pilot-in-command and n a v i g a t o r escaped t h r o u g h t h e l e f t s i d e c o c k p i t
s l i d i n g window.

I n t h e s e c t i o n r e a r of s e a t row 1 3 , t h e r e were 54 p a s s e n g e r s and 5 crew


members. Ten p a s s e n g e r s and 5 crew members escaped through t h e l e f t s i d e rear p a s s e n g e r
door.

Cabin s t a f f from t h e f r o n t s e c t i o n were u n a b l e t o g a i n f u r t h e r a c c e s s t h r o u g h


t h e c a b i n t o t h e r e a r due t o f i r e which d i v i d e d t h e c a b i n a t row 1 5 r e n d e r i n g movement
through i t i m p o s s i b l e .
148 ICAO C i r c u l a r 8&AN/74

Most of t h e b o d i e s were found s e v e r e l y burned i n t h e a f t s e c t i o n of t h e


economy c l a s s c a b i n , l y i n g i n t h e d e b r i s w i t h t h e heads i n t h e d i r e c t i o n of t h e r e a r of
t h e a i r c r a f t , pyramided between t h e last t h r e e rows of s e a t s .

F a i l u r e of t h e c a b i n l i g h t s a f t e r f i r s t impact r e n d e r e d e v a c u a t i o n a c t i o n
more d i f f i c u l t .
W h i l s t a s s i s t a n c e was r e n d e r e d by some of t h e c a b i n s t a f f i n t h e f r o n t sec-
t i o n w i t h t h e e v a c u a t i o n of some of t h e 11 s u r v i v i n g p a s s e n g e r s from s e a t row 1 3 forward
through t h e f r o n t l e f t - h a n d d o o r , t h e Commission n o t e s t h a t 6 p a s s e n g e r s from s e a t row 11,
who s u b s e q u e n t l y d i e d , d i d n o t w a c u a t e t h r o u g h t h e f r o n t s e c t i o n w i t h t h e o t h e r s . The
i n t e n s i t y of t h e f i r e which s t a r t e d i n t h e wing a r e a , and d i v i d i n g t h e f u s e l a g e i n t o two
s e p a r a t e s e c t i o n s a t row 1 5 , undoubtedly p r e v e n t e d t h e c a b i n s t a f f from t h e f r o n t i n
rendering a s s i s t a n c e t o those passengers f u r t h e r i n t h e r e a r .

The m a j o r i t y of t h e 4 4 p a s s e n g e r s i n t h e a f t s e c t i o n rear of s e a t row 1 3 who


d i d n o t s u r v i v e and who d i d n o t r e c e i v e ante-mortem f r a c t u r e s o r t r a u m a t i c i n j u r i e s were
c a p a b l e of movement a f t e r t h e c r a s h . The p o s i t i o n of most of t h e b o d i e s r e v e a l e d t h a t
t h e r e w a s c o n s i d e r a b l e movement i n t h e r e a r of t h e c a b i n toward and i n t h e d i r e c t i o n of t h e
r e a r door a f t e r t h e 1 0 p a s s e n g e r s and 5 crew members had e v a c u a t e d through t h e l e f t r e a r
p a s s e n g e r door. C o n s i d e r a b l e c o n f u s i o n and crowding i n t h e narrow a i s l e must have e x i s t e d
i n t h e d a r k n e s s , and e g r e s s made e x t r e m e l y d i f f i c u l t by t h e number of o b s t r u c t i o n s , t h e
p r e s e n c e of dense smoke and fumes and t h e i n t e n s e h e a t of t h e r a p i d l y s p r e a d i n g f i r e
t h r o u g h t h e f u s e l a g e toward t h e rear and i n o r d i n a t e and a l t e r n a t e movement w i t h i n t h e
cabin.

Although t h e l e n g t h of t i m e t a k e n f o r t h e f i r e t o encompass completely t h e


a i r c r a f t w a s n o t determined, t h e evidence i n d i c a t e s t h a t t h i s s p r e a d w a s d e f i n i t e l y a t a
f a s t e r r a t e t o t h e rear. And w h i l e t h e c a b i n a t t e n d a n t s who were not i n c a p a c i t a t e d by
i n j u r y a s s i s t e d some of t h e s u r v i v i n g p a s s e n g e r s a f t e r e v a c u a t i n g through t h e f r o n t and
rear d o o r s , t h e Commission b e l i e v e s t h a t had f u r t h e r a s s i s t a n c e been r e n d e r e d t o t h o s e
s t i l l i n s i d e a d d i t i o n a l l i v e s might p o s s i b l y have been saved.

The work of t h e c r a s h r e s c u e s e r v i c e s was c a r e f u l l y a n a l y s e d . It must be


concluded t h a t t h e crew w a s f u l l y a l e r t when t h e a i r c r a f t approached t h e aerodrome and were
r e a d y f o r a c t i o n when t h e a l a r m b e l l r a n g and ATC i n s t r u c t e d them where t o go. They
immediately s t a r t e d t o a t t a c k t h e f i r e by a p p l y i n g foam on t h e f u s e l a g e t o keep i t as c o o l
as p o s s i b l e and e x t e n d t h e t i m e f o r t h e f u s e l a g e t o become consumed by f i r e . The Commis-
s i o n is of t h e o p i n i o n t h a t a small crew of 5 manning two c r a s h t r u c k s could n o t , a f t e r a
minimum e l a p s e t i m e of 7 m i n u t e s and 40 seconds t o r e a c h t h e s c e n e of t h e a c c i d e n t , have
r e n d e r e d any v a l u a b l e e v a c u a t i o n a s s i s t a n c e a t t h e r e a r . When t h e f i r e c h i e f a r r i v e d
s h o r t l y a f t e r t h e a r r i v a l of t h e f i r e crew, h e a s c e r t a i n e d himself by l o o k i n g through t h e
open f r o n g l e f t - h a n d door t h a t nobody c o u l d be saved from t h e f r o n t p a r t of t h e c a b i n . An
e r u p t i o n of a f u e l t a n k p r e v e n t e d him from l o o k i n g i n t o t h e rear c a b i n a t t h e r e a r door
when h e w a s about t o do s o . A s t h e small f i r e crew was f u l l y occupied by f i g h t i n g t h e
f i r e , it was beyond t h e i r p h y s i c a l c a p a b i l i t i e s t o e f f e c t r e s c u e .

The Commission t h e r e f o r e b e l i e v e s t h a t more l i v e s might have been saved i n


t h i s a c c i d e n t i f t h e crew members, who esc,,-:d r e l a t i v e l y u n h u r t , had d i r e c t e d more e f f o r t
i n f u r t h e r e v a c u a t i o n and t h e c r a s h r e s c u e s e r v i c e had c a r r i e d more manpower t o e f f e c t
immediate r e s c u e .
ICAO C i r c u l a r 88-AN/ 74 149

2.- A n a l y s i s and Conclusions


2.1 Analysis

There w a s no s t r u c t u r a l , powerplant, systems, o r n a v i g a t i o n a l components


on board t h e a i r c r a f t t h a t c o n t r i b u t e d t o t h e c a u s e of t h i s a c c i d e n t . The a i r c r a f t w a s
c u r r e n t l y c e r t i f i c a t e d , and, a s f a r as c o u l d be a s c e r t a i n e d , a i r w o r t h y , p r o p e r l y m a i n t a i n e d
and d i s p a t c h e d i n accordance w i t h t h e company o p e r a t i o n a l p r o c e d u r e s .

Testimony and i n v e s t i g a t i o n d i s c l o s e d t h a t a l l ground a i d s and n a v i g a t i o n a l


f a c i l i t i e s were o p e r a t i n g s a t i s f a c t o r i l y a t t h e t i m e of t h e a c c i d e n t .

A l l communications between a i r c r a f t and ATCO were normal.

During t h e d e s c e n t , t h e f l i g h t encountered some s t r a t u s and f u r t h e r l a t e r


down f o g p a t c h e s which had n o t been i n c l u d e d i n t h e m e t e o r o l o g i c a l i n f o r m a t i o n g i v e n t o
t h e p i l o t s a t between 0230 and 0235 h o u r s ( i . e . t h e 0200 h o u r s weather o b s e r v a t i o n ) . From
t h e a v a i l a b l e e v i d e n c e , i t i s c l e a r t h a t t h e a c t u a l c o n d i t i o n s have m a t e r i a l l y c o n t r i b u t e d
t o t h e a c c i d e n t , b u t i t i s obvious t h a t any pilot-in-command of a modern t r a n s p o r t a i r c r a f t
i n any l a n d i n g must be a b l e t o cope w i t h t h e s e c o n d i t i o n s i n a . s a f e way. The f l i g h t was
n o t complicated by wind, t u r b u l e n c e o r r a i n .

During t h e f i n a l approach, t h e pilot-in-command d i d n o t make u s e of a l l


a v a i l a b l e n a v i g a t i o n a l equipment. H e had announced t o t h e c o - p i l o t t h a t he would make an
IFR approach, but i n doing s o he d i d n o t make any u s e of t h e DME equipment. Had he u s e d
same, h e would have been a b l e t o d e t e c t a t a n e a r l i e r s t a g e t h a t he w a s t o o high. This
would have avoided an i n c o r r e c t a l t i t u d e a t a l a t e r c r i t i c a l s t a g e .

I n t h i s r e s p e c t , it is of importance t h a t t h e pilot-in-command s t a t e d t h a t
h i s a l t i t u d e over t h e c o a s t w a s 1 500 f t . However, t h e c o - p i l o t d e c l a r e d t h a t i n t h i s
p o s i t i o n he saw t h e VASI l i g h t s a l l w h i t e . A f l i g h t test r e v e a l e d t h a t t h i s i s o n l y pos-
s i b l e i f t h e minimum a l t i t u d e a t t h e c o a s t amounts t o 1 800 f t . From t h e a v a i l a b l e e v i d e n c e
i t i s c l e a r t h a t t h e pilot-in-command c a r r i e d o u t a r o u t i n e d e s c e n t a t t h e c o r r e c t speed
and t h e c o r r e c t rate of d e s c e n t , but n o t b e f o r e h e reached FR, d i d he d i s c o v e r t h a t he was
about 300 f t h i g h e r t h a n h e had supposed.

The Commission c o n s i d e r s t h e f a i l u r e of t h e pilot-in-command t o make u s e of


t h e DME a s e v e r e shortcoming.

A t t h i s s t a g e , a n a c c i d e n t could have been avoided had t h e pilot-in-command


decided t o abandon h i s approach, climbed t o t h e p r e s c r i b e d a l t i t u d e and made a new approach
from t h e c o a s t p o s i t i o n . However, though he knew t h e f i e l d was n o t i n s i g h t , he d e c i d e d .
t o l o s e h i s e x c e s s a l t i t u d e by i n c r e a s i n g h i s r a t e of d e s c e n t t o 1 200-1 500 f t / m i n by
r e d u c i n g t h e e n g i n e power and s i m u l t a n e o u s l y p i t c h i n g t h e a i r c r a f t i n a more nose-down
a l t i t u d e . T h i s procedure i s c o n t r a r y t o t h e o p e r a t o r ' s i n s t r u c t i o n s which p r o h i b i t t h e
u s e of a d e s c e n t r a t e of g r e a t e r t h a n 1 000 f t p e r minute below a n a l t i t u d e of 2 000 i t .

A r a p i d s i n k developed, which t h e pilot-in-command i n t e n d e d t o s t o p when t h e


i n d i c a t e d a l t i t u d e was e x a c t l y 500 f t . The r a p i d change of s t a t i c p r e s s u r e c e r t a i n l y w i l l
have caused a d e l a y i n i n d i c a t i o n of t h e s t a t i c i n s t r u m e n t s , s o &at t h e r e a l h e i g h t a t
t h i s moment must have been less. Whether t h e amount of power a p p l i e d w a s t h e maximum
1 50 ICAO C i r c u l a r 88-AN/74

II
a v a i l a b l e power is n o t known; t h e second o f f i c e r s t a t e d : H e o n l y a p p l i e d a smal. 3mount
of power n o t enough t o go around." Because a jet a i r c r a f t does n o t r e a c t immediately i n
a v e r t i c a l s e n s e when power is a p p l i e d , as f i r s t t h e speed h a s t o i e i n c r e a s e d , a con-
s i d e r a b l e l o s s of a l t i t u d e o c c u r s b e f o r e l e v e l f l i g h t i s a c h i e v e d . Evidence r r . v e s ~ s - dt h a t
t h e f i n a l a n g l e of d e s c e n t was a t l e a s t 4.5O, t h e r e b y i n d i c a t i n g t h a t t h e -i-hievemer -
l e v e l f l i g h t was f a r from b e i n g r e a l i z e d . Also t h e i m p r e s s i o n of b o t h main l a n d i n g
and t h e n o s e g e a r a t t h e f i r s t p o i n t of impact i n d i c a t e d t h a t t h e a i r c r a f t v a s
a nose-down a t t i t u d e a t impact.

2.2 Conclusions

(a) Findin~s

Based on t h e f o r e g o i n g , t h e Commission b e l i e v e s t h e f o l l o w i n g c o n c l u s i o n s
a r e j u s t i f ied:

No f a c t o r s a p a r t from t h o s e mentioned below have b e e n found which may have


contributed t o t h e accident.

The c a p t a i n d i d n o t make u s e of t h e a v a i l a b l e n a v i g a t i o n a l a i d s by d i s r e g a r d -
i n g t h e i n d i c a t i o n s of h i s d i s t a n c e measuring equipment d u r i n g f i n a l approach.

A t a n a l t i t u d e below 1 000 f t , t h e a i r c r a f t e n t e r e d a s t r a t u s l a y e r , which


a t t h a t tiine c o m p l e t e l y o b s c u r e d t h e runway.

A t t h e FR, p o s i t i o n e d 1.7 NM b e f o r e t h e runway t h r e s h o l d , t h e p i l o t - i n -


command saw t h a t h i s a l t i t u d e w a s 800 f t , whereas t h e c o r r e c t a l t i t u d e should have
been 520 f t . C o n t r a r y t o company i n s t r u c t i o n s , h e i n c r e a s e d h i s rate of d e s c e n t
t o between 1 200-1 500 f t / m i n by r e d u c i n g e n g i n e power and p i t c h i n g t h e nose of t h e
a i r c r a f t down, w i t h t h e i n t e n t i o n t o arrest h i s d e s c e n t a t a b o u t 500 f t .

The a t t e m p t t o level o f f was i n s u f f i c i e n t a n d / o r t o o l a t e , w i t h t h e r e s u l t


t h a t t h e a i r c r a f t touched t h e ground some 6 000 f t b e f o r e t h e runway t h r e s h o l d when
h i s g l i d e p a t h a n g l e must have been 4.50 o r more.

During impact and t h e s u b s e q u e n t ground s l i d e of a b o u t 850 i t , t h e a i r c r a f t


b r o k e , u p and caught f i r e .

Those crew members who e s c a p e d r e l a t i v e l y u n h u r t , once o u t s i d e , might have


d i r e c t e d more e f f o r t i n f u r t h e r e v a c u a t i o n .

The f i r e crew a c t e d promptly, b u t i t s l i m i t e d f o r c e and t h e n e c e s s a r y e l a p s e


time t o r e a c h t h e s c e n e of t h e a c c i d e n t p r e v e n t e d them from s a v i n g p e o p l e who might
n o t y e t have d i e d .

(b) Cause o r
Probable cause(s)

The p r o b a b l e c a u s e of t h i s a c c i d e n t w a s t h e f a i l u r e of t h e pilot-in-command
t o arrest i n t i m e t h e f a s t d e s c e n t a t a low a l t i t u d e upon which h e had e r r o n e o u s l y d e c i d e d ,
i n s t e a d of e x e c u t i n g a missed approach when h e found h i m s e l f t o o h i g h o v e r t h e l o c a t o r
beacon.

Scheduled i n t e r n a t i o n a l
Landing
Undershoot
I C A O Ref: XR/002/67 L ~ i l o tmisjudged d i s t a n c e I

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