Six Hours and 26 Minutes into a Four Hour, 40 Minute Flight

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • MARCH 1992 1

“On January 25, 1989, at approximately 2134eastern standard time, Avianca Airlines flight052 [AVA 052], a Boeing 707-321B with Colom-bian registration HK 2016, crashed in a woodedresidential area in Cove Neck, Long Island,New York. [U.S.] AVA 052 was a scheduledinternational passenger flight from Bogotá,Colombia, to John F. Kennedy InternationalAirport [JFK], New York, with an intermedi-ate stop at Jose Maria Cordova Airport, nearMedellin, Colombia. Of the 158 persons aboard,73 were fatally injured.” So began the accidentsummary of the U.S. National TransportationSafety Board (NTSB) in its report of an aircraftaccident that would highlight numerous safetyissues.

Because of poor weather conditions in the north-eastern United States, AVA 052 was placed inholding patterns three times by air traffic con-trol (ATC) for a total of approximately onehour and 17 minutes. During the third hold-ing pattern, the flight crew reported that theairplane could not hold longer than five min-utes, that it was running out of fuel and that itcould not reach its alternate airport, BostonLogan International in Massachusetts. Subse-quently, after being cleared for an approach,

the flight crew executed a missed approach toJFK. While returning to the airport, the air-plane experienced a loss of power to all fourengines and crashed approximately 16 milesfrom the airport.

Problems Accumulated Early

The following is a brief reconstruction fromthe accident report of how the crew’s prob-lems accumulated.

• The captain ordered approximately 6,000pounds of fuel, or a possible 30-45 min-utes of extra flight, added prior to de-parture from Medellin. This raised theaircraft’s takeoff weight to the airfieldperformance limit. If the flight had ex-perienced no delays, it would have landedat JFK with more than 20,000 pounds,or approximately two hours flight timeof fuel remaining.

• The weather data provided to the flightcrew before departing Medellin was nineto 10 hours old. It indicated that JFKhad weather no worse than a 400-foot

Six Hours and 26 Minutes into aFour Hour, 40 Minute Flight

The stage is set for disaster when a weary internationalcrew assumes that air traffic control is aware

that a fuel emergency exists.

byCapt. Tom Duke

Aviation Safety Writer

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • MARCH 19922

ceiling, one mile visibility and windsgusting to 25 knots with light rain. Thealternate, Boston, however, was reportedas intermittently below legal minimumsfor filing as an alternate airport.

• Except for the short leg from Bogotá toMedellin, the captain had not flown pre-viously with either the first officer orengineer. He chose to fly the leg to JFK.According to the cockpitvoice recorder (CVR), thefirst officer made all theradio calls in English andrepeated air-ground com-munications to the captainin Spanish.

• The engines of the aircrafthad been modified withhush kits that, along withother factors such as ageand cumulative wear andtear on the aircraft’s aero-dynamics and powerplantefficiency, degraded fuelconsumption approximately 10 percent;this was considered in the fuel plan-ning. Landing procedures for this air-craft call for the use of only 25 degreesof flaps during landing for noise toler-ance except when authorized for emer-gency procedures. However, use of theautopilot during approaches with 25degrees of flaps is not allowed below500 above ground level (agl). Coupledautopilot approaches with 40 to 50 de-grees of flaps are certified to 62 feet aglbut because of the noise limitation, mayonly be used in an emergency.

• Aircraft records indicated recurring au-topilot problems. A captain who hadflown this aircraft on the flight just priorto the accident flight indicated therewas a problem with the flight directorin the approach mode. The NTSB re-port stated the belief that AVA 052 mighthave been flown manually from Colombiaand that the approach was flown with-out the aid of a flight director.

• The crew of AVA 052 did not use avail-able flight dispatch services to updateweather and alternate airport informa-tion and might not have been aware ofthe deteriorated weather conditions atJFK by the time they reached Norfolk.

• The flight plan showed that AVA 052was early by approximately eight min-utes at Norfolk and had used up much

of the extra fuel loaded at Medellin.This may have been the result offlying faster, heavier and at a loweraltitude than the original flightplan. After holding at Norfolk for19 minutes before heading towardJFK, the aircraft departed 37,000feet with 17,000 pounds of fuel at1942 hours, approximately 20 min-utes behind scheduled flight plan“top of descent” time. The required10 percent reserve fuel and extra6,000 pounds was almost gone.Without further delay, AVA 052could expect to land at JFK with14,500 pounds of fuel. This would

be sufficient for about one hour and 30minutes of flight at approach altitudesand still leave slightly more than the12,400 to 14,100 pounds required to goto the Boston alternate and hold for 30minutes before running out of fuel.

• At 1943, near Atlantic City, N.J., at Botonintersection, AVA 052 was held again,for 29 more minutes. While holding atBoton, the flight crew received severalaltitude change clearances to 19,000 feetand two expect further clearance (EFC)changes. The crew requested informa-tion about Boston delays from Wash-ington Center and were informed thatBoston was accepting traffic and thatJFK would have to hold them “at most30 more minutes.” Three minutes afterhearing that news at 2006, the AVA 052crew informed ATC that they wantedto proceed to JFK, not Boston. At thattime, they might have had approximately14,000 pounds of fuel remaining.

By accepting the clearance to JFK with

The crew …might not havebeen aware of

the deterioratedweather

conditions … .


the prospect of a 30-minute hold, theAVA 052 crew accepted the fact thatthey would not have enough fuel forany subsequent holding en route to Bos-ton. With no more than a 30-minutehold, they could forecast about 4-5,000pounds of fuel, less than 30 minutes offlight, on landing. At this point, thedecision to land at Kennedywas the least-worst choicebecause, as the NTSB reportstated, the airplane did nothave sufficient fuel to fly toits alternate airport. The flightc r e w n e v e r i n f o r m e dAvianca’s contract dispatcherat Kennedy of their fuel situ-ation or asked for assistance.The weather at nearby Phila-delphia, Pa., closer than Bos-ton, was no lower than 700foot ceilings and one halfmile visibility during thistime period and for the re-mainder of the flight.

• AVA 052 then held at Camrn intersec-tion, 39 miles south of JFK, for 29 min-utes from 2018 to 2047. At 2031, it wascleared to JFK and descended to 11,000feet. However, because of missed ap-proaches ahead of it, the aircraft wassent back to Camrn at 2037. At 2044,without a new EFC, AVA 052 asked for“estimates” and in the next minute ATCfirst cleared it to Kennedy, then gave itan EFC of 2105. The AVA 052 crew thenstated, “Well I think we need priority...”and ATC asked them how long theycould hold and what was their alter-nate. At 2046, the crew told JFK theycould hold five minutes that their al-ternate “was Boston but we think wecan’t do it now we, we, don’t, we runout of fuel now.”

Twenty three seconds later, AVA 052was cleared to Kennedy. It was told toswitch frequency to Kennedy approachcontrol and was in contact by 2047. Noinformation about remaining fuel in min-utes was offered by the flight crew or

requested by ATC. Apparently assum-ing they had asked for priority traffichandling, and therefore had declaredan emergency, the Avianca flight crewdid not use the words “emergency” or“Mayday.” By now, they probably hadless than 10,000 pounds — less than anhour — of fuel remaining.

The aircraft manufacturer suggestslanding the 707-321B with no lessthan 7,000 pounds, but some air-lines and the U.S. Federal AviationAdministration (FAA) treat that asinformational and not a requiredminimum amount. It is likely AVA052 would now be landing with lessthan 7,000 pounds of fuel remain-ing even if there were no furtherdelays.

[Avianca’s route manual on the sub-ject of flight crew and ATC proce-dures for a minimum fuel situation

requires pilots to: (1) Advise ATC ofyour minimum fuel status when yourfuel supply has reached a state where,upon reaching destination, you cannotaccept any undue delay. (2) Be awarethis is not an emergency situation butmerely an advisory that indicates anemergency situation is possible shouldany undue delay occur. (3) Be aware aminimum fuel advisory does not implya need for traffic priority. (4) If the re-maining usable fuel supply suggests theneed for traffic priority to ensure a saferlanding, you should declare an emer-gency, account low fuel, and report fuelremaining in minutes.]

• Approach control directed AVA 052 toslow to 180 knots and cleared it to DeerPark Intersection for a runway 22L ap-proach and to descend to 7,000 feet at2048. The cockpit voice recorder (CVR)follows the scenario at 2053 for the next40 minutes to the crash. Because thecontroller for Camrn did not hear partof the transmission about “we run outof fuel now,” he did not pass that criti-cal information to approach control. The

“ … we thinkwe can’t do itnow we, we,don’t, we run

out of fuelnow.”


Manual elevator trim inputs were heardon the CVR transcript. On final approach,the crew had problems maintaining air-speeds requested by the tower control-ler. The final approach was very un-stable. The captain used 50 degrees offlaps. That setting causes higher fuelburn but the aircraft is easier to handlethan with the normal 25-degree flap set-ting. At three miles from the runway,the aircraft rapidly went above glide-path and then well below, possibly froma windshear. At 2.3 miles from the run-way, with the ground proximity warn-

ing system (GPWS) repeatedlysounding “whoop whoop pull up,”the crew leveled the aircraft at200 feet and began looking for therunway lights.

At 2123:23 the captain asked, “Therunway, where is it?”

At 2123:27 the first officer re-sponded, “I don’t see it, I don’tsee it.”

At 2123:28, after eight-seconds offlying 200 feet above the popu-lated area below, they began a

missed approach .8 mile short of themissed approach point. The urgency ofthe GPWS alarms added to the crew’sother stresses and could have made themanxious to expedite a missed approach,which decreased their opportunity tosee the runway environment. There wasno communication from the control towerconcerning their dangerously low alti-tude and below-glideslope condition.

• From missed approach to fuel exhaus-tion was approximately 10 minutes.During the initial stage of the missedapproach, the captain told the first offi-cer, “Tell them we are in emergency.”

The first officer then told ATC, “ …we’ll try once again we’re running outof fuel.”

The tower responded, “Okay.”

The CVRconversation

containedample evidenceof fatigue and

stress … .

use of the term “priority” by the Avi-anca first officer did not key a thoughtprocess connoting “critical situation”or “emergency” to ATC. Approach controlgave AVA 052 routine handling whilethe flight crew members apparently be-lieved they were known to be needingpriority treatment, or no further delays.They were given another six- to eight-minute delaying vectored circle and along 15-mile final approach leg, but didnot complain. The flight engineer briefedfor an emergency low-fuel missed ap-proach procedure as required when thereis less than 1,000 poundsof fuel per main tank (4,000pounds total) remaining.

The first officer repeated allATC instructions to the cap-tain in Spanish; the captainapparently had difficultyhearing him because he re-quested several repeats. TheCVR conversation containedample evidence of fatigueand stress, and indicationsof flight director and ILSradio tuning and settingproblems. The engineer wasasked to set power using rpm setting,an indication that the captain might havehad a problem with throttle alignmentand insufficient time to cross check powersettings.

The Automatic Terminal Information Ser-vice (ATIS) recording indicated “200 skyobscured visibility 1/4 mile” and a 17-knot, slightly left crosswind. [Parallelrunway 22R was below its 250-3/4 mini-mums.] The runway visual range (RVR)was 6,000 feet (more than the 2,000 feetrequired), and a moderate 10-knot wind-shear was reported to an aircraft closelyfollowing AVA 052. However, the lat-est RVR and the windshear report werenot directed to AVA 052 by the localcontrol tower operator.

• There are no conversations on the CVRindicating that the autopilot was in use.


The captain then asked the first officer,“What did he say?”

The first officer repeated his own trans-mission to the tower in Spanish.

The captain again said, “Advise himwe are emergency.” Then he asked, “Didyou tell him?”

The first officer, possibly preoccupiedwith a windshear report being given toanother aircraft on the ra-dio, responded, “Yes, sir. Ialready advised him.”

The word “emergency” or“Mayday” was still not statedor transmitted by the firstofficer. The crew was toldto continue the left turn to150 degrees.

• After vectoring the aircraftaway from the field, at2124:39 the tower switchedAVA 052 to approach con-trol. When changing frequency to ap-proach control, the first officer reported“… we’ve missed … and we’re main-taining 2,000 ...”

The new controller gave no indicationthat he was aware of the urgency of thesituation and did not inquire if theywere in an emergency status as he clearedthem to climb to 3,000 feet.

The captain again ordered the first offi-cer, “Advise him we don’t have fuel.”

The first officer radioed, “Climb andmaintain 3,000 and ah we’re runningout of fuel.”

Approach responded, “Okay, fly head-ing zero eight zero.”

The first officer read back the clearanceand told the captain, “Three thousandfeet, please” without advising the cap-tain of the heading change.

He incorrectly responded “one hundredeighty” upon inquiry of the captain aboutthe new heading.

The captain again challenged the firstofficer, “Did you already advise thatwe don’t have fuel?”

The first officer responded in Spanish,“Yes sir, I already advise[d] him hun-dred and eighty on the heading we aregoing to maintain three thousand and

he’s going to get us back.”

The captain said, “Okay.”

• The flight had proceeded south,away from the airport, for morethan a minute before approach con-trol gave AVA 052 a new headingto 070 and transmitted “I’m gunnabring you about fifteen miles northeast and then turn you back ontothe approach is that fine with youand your fuel?”

The first officer responded, “I guessso thank you very much.”

The Captain asked, “What did he say?”

The flight engineer said, “The guy isangry.”

The first officer said, “Fifteen miles inorder to get back to the localizer.” Thetime was 2126:47, less than six minutesto fuel exhaustion.

• At 2129:11, when they were approxi-mately abeam the outer marker, AVA052 asked approach control, “Can yougive us a final now?”

Approach responded, “Affirmative sirturn left heading 040.” This new headingwas the reciprocal of the landing runwayand would take the aircraft for a long15-mile final, not a shortened approach.A minute later at 2130:14, approach clearedanother aircraft for a “left turn two fivezero and … cleared for ILS.”

The newcontroller gaveno indicationthat he wasaware of the

urgency of thesituation … .


Avianca’s first officer read back the clear-ance as if it had been meant for AVA052. The captain made the turn, left al-titude and then AVA 052 was told to“… climb and maintain 3,000 feet” byapproach control.

At 2130:36, the first officer told approach,“Negative sir we just running out offuel...”

Approach then turned AVA 052 to a head-ing of 310 degrees, perpendicular to fi-nal course, then to a heading of 360 de-grees with the explanation that “you’renumber two for the approachI just have to give you enoughroom so you make it without… having to come out again.”

At 2132:11, approach turnedAVA 052 to 330 degrees andseconds later the engineflameouts began. At 2132:49,the first officer reported, “Wejust … lost two engines and… we need priority please.”

Approach turned them left to 250 de-grees to intercept the localizer and at2133.04 stated, “Avianca zero five twoheavy you’re one five miles from theouter marker maintain two thousanduntil established on the localizer clearedfor ILS two two left.”

The first officer responded, “Roger,Avianca.” It was their last transmis-sion. The CVR tape’s power was lost 12seconds later.

In very low ceilings, driving rain andgusty winds during darkness, AVA 052glided to a crash landing in a woodedneighborhood. The upslope impact intrees was gentle enough for 85 of the158 persons on board to survive theimpact forces. From the appearance ofthe cabin, none of the passengers waswarned of the impending crash. Therewas no last minute electrical power avail-able to the cabin speaker system.

• At 0234:00 the final controller called,“Avianca zero five two you have uhyou have enough fuel to make it to theairport?” It was too late.

• At 2135, just after AVA 052 had disap-peared from radar, a special weatherobservation indicated improvement to300 foot ceiling and 3/4 mile visibility,RVR (runway visual range) 5,500-6,000feet.

• In retrospect, the flight might have beenable to receive a shortened approachand perhaps have returned after the

missed approach had the flight crewopenly stated they had a fuel emer-gency, used the word “Mayday” orrefused the climbs and vectors. NewYork’s controllers never becameaware of the extreme urgency, didnot volunteer to ask the flight crewif they had an emergency fuel situ-ation or ask if they had enough fueluntil they heard the word “flame-outs.” “We’re running out of fuelsir,” did not elicit a sense of ex-treme urgency on the part of the

controller, according to the taped con-versation.

• This accident reflects the combinationof multiple events that eventually be-come overwhelming and result in a di-saster. There was a long string of air-ground miscommunications and unveri-fied misunderstandings, poor flight plan-ning decisions, poor crew coordination,poor company dispatch and avionicssupport procedures and rules, worsethan forecast weather and an unexpectednumber of delays. The result was ex-treme crew stress and fatigue that ledto inadequate communications and apoorly executed approach and missedapproach circuit … and ultimately fuelexhaustion.

AVA 052 had been a challenge from the begin-ning; a four hour 40 minute flight ended sixhours and 26 minutes later on a wooded hill-side. As the report succinctly states, “If the flight

“We just …lost two

engines and …we needpriorityplease.”


crew of AVA 052 had been able to complete thefirst ILS approach and land successfully, theaccident would not have occurred … .”

Background Details Set Scene

The goal of the AVA 052 flight crew was tocomplete a safe, on-time flight to JFK. Theirscheduled arrival time was during busy inter-national arrival hours in the early evening whenmany domestic feeder airlines are also mak-ing connections. As part of the U.S. NationalAirspace System (NAS), a Central Flow Con-trol Facility (CFCF) located at FAA Headquar-ters in Washington, D.C., attempts to managethe flow of traffic into especially busy airportsthroughout the country such as JFK. Domesticflights headed for airports experiencing land-ing delays are held by CFCF on the ground atthe U.S. departure airports until the threats ofinflight holding dissipate. This is a fuel-sav-ing procedure and an excellent safety prac-tice. Foreign arrivals, however, are not subjectto CFCF ground delays and are fedinto the system while airborne.

Because the weather situation at JFKon that January day became worsethan predicted and the wind con-ditions and low ceilings did notallow the use of two runways forlandings, the expected airport ac-ceptance rate of 33 aircraft arrivalsper hour became drastically reducedand arrivals began backing up. Rout-ing for AVA 052 placed the aircrafton an arrival route from the south where itwas placed in a trail of other traffic and heldwith many domestic carriers originating frompoints south of Norfolk, Virginia.

The main impediment to AVA 052 arriving ontime was excessive holding caused by earliermissed approaches by other aircraft at JFK duemainly to difficulties pilots were having withwindshear, low ceilings and visibility. Air trafficcontrollers were also having trouble keepingproper aircraft separation because there werestrong and varying tailwinds of approximately70 knots on the downwind leg and headwindsof 30 knots or more on final that were forcing

“breakouts,” or ATC-directed missed approaches.The problem was not only one of maintainingaircraft spacing in sequence for aircraft arriv-ing from many directions but one of fittingmissed approach aircraft back into the trafficpattern. This caused further delays that re-sulted in extra holding times for others fol-lowing in sequence. For example, the aircraftlanding just ahead of AVA 052 had been workedback into the pattern after an ATC-directedmissed approach, when the captain expressedconcern about low fuel; he successfully madehis second approach using the autopilot.

The Avianca flight was to become one of 22missed approaches that afternoon and eveningat JFK. At least 23 other flights were divertedto other airports. Each missed approach ac-counted for a three- to an eight-minute extrahold for other aircraft heading to JFK. TheNTSB report did not mention how long otherarriving flights were held or delayed.

This unanticipated situation caused AVA 052to hold three times beginning atNorfolk for a total of one hour, 17minutes plus another eight-minutevectored circle after the crew toldcontrollers they were then so lowon fuel that they could not go totheir alternate. The ATC controllerswere busy with rapidly changing situ-ations and they did not hear every-thing that flight crews were trans-mitting, or pass all information onto the next controller in the sequence.Flight separation requirements var-

ied from 20 miles en route to five-miles onfinal. There was little time for interruptions orextra clarification by air traffic controllers.

As a result of this hectic situation, by the timeof their first approach to Kennedy, the flightcrew of AVA 052 had logged six hours, 17 min-utes on a planned four hour, 40-minute flight.The NTSB stated that it believes that AVA 052and its dispatcher should have kept each othermore informed before the emergency situa-tion developed.

In order to make a decision to go to an alter-nate when the destination is at or near mini-

The Aviancaflight was tobecome one of

22 missedapproaches … .


mums, one of the facts a captain wants to knowis when to expect to land. The only hard infor-mation the AVA 052 flight crew was able toobtain was EFC times which ATC must givecrews in the event of lost communications.Because of the dynamics of the situation thatevening, an expected landing time could notbe predicted by either the crew or ATC. One ofthe variables was the number of aircraft aheadof AVA 052 that would miss their approachesand how many of them that would proceed totheir alternate airports. The flow plan did notadequately consider extra approaches.

Probable Cause Determined

The NTSB determined that the probable causeof this accident was the failure of “the flightcrew to adequately manage the airplane’s fuelload, and their failure to communicate an emer-gency fuel situation to air traffic control be-fore fuel exhaustion occurred.” Contributingto the accident according to the board, was“the flight crew’s failure to use an airline op-erational control dispatch system to assist themduring the international flight into a high-densityairport in poor weather. Also contributing tothe accident was inadequate traffic flow man-agement by the [U.S.] Federal Avia-tion Administration [FAA] and thelack of standardized understandableterminology for pilots and control-lers for minimum and emergencyfuel states.”

The board also determined that wind-shear, crew fatigue and stress werefactors that led to the unsuccessfulcompletion of the first approach, andthus contributed to the accident.

Numerous safety issues were raisedin the NTSB report. They include:

• Pilot responsibilities and dispatch re-sponsibilities regarding planning, fuelrequirements and flight following dur-ing international flights;

• Pilot to controller communications re-garding the terminology to be used to

convey fuel status and the need for specialhandling;

• ATC flow control procedures and re-sponsibilities to accommodate aircraftwith low fuel states; and,

• Flight crew coordination and Englishlanguage proficiency of foreign crews.

Recommendations concerning these issues wereaddressed to the FAA and the Director,Departmento Administrativo de AeronauticoCivil (DAAC), Colombia.

Conclusions Reviewed

It is appropriate for this discussion to reviewall of the 24 findings listed in the NTSB re-port. In parentheses following some findingsare the person(s) and main category of hu-man performance factor or error. The find-ings are below:

1. The accident occurred when the airplane’sengines lost power as a result of fuel exhaus-tion while the flight was maneuvering for asecond instrument approach to JFK airport.

2. Examination of the airplane revealedno malfunction of the engines or fuelsystem components that could havecaused a premature fuel exhaustion.

3. The flight crew was not providedwith, and they did not request be-fore departure, the most currentweather forecast available for thedestination or selected alternate air-port. (captain, flight planning/dis-patcher, flight planning)

4. The alternate airport selected forthe flight at the time of departure

did not meet the prescribed weather criteriafor an alternate based on weather informationprovided to the crew at the time of departure.The weather conditions worsened at both thedestination and alternate while the flight wasen route. (captain, flight planning/airline dis-patcher, flight planning)

… failure …to adequately

manage theairplane’s fuelload, and … tocommunicatean emergency

fuelsituation … .


5. The flight plan for AVA 052 did not reflectthe most current upper air data or the actualgross weight of the aircraft upon departurefrom Medellin. (captain, flight planning/dis-patcher, flight planning)

6. The flight crew had received appropriateflight and ground training for theflight, and they possessed appro-priate flight and medical certifica-tion required by the governmentof Colombia.

7. The flight crew was experiencedin conducting Boeing 707 flightsfrom Colombia to the United States.

8. There was no flight following orinteraction with the Avianca Air-lines dispatcher for AVA 052 fol-lowing takeoff from Medellin. None was re-quired by the airline’s operations specificationsissued by the FAA under 14 Code of FederalRegulations (CFR) 129, the U.S. regulation thatcovers non-U.S. air carriers operating into theUnited States. (dispatcher, flight planning/DAACrulemakers, organizational oversight/airlineoperations, organizational oversight)

9. There is no record that while en route theflight crew requested updated weather infor-mation from any source regarding the desti-nation or alternate airport. (captain, flight plan-ning)

10. The flight crew did not adequately com-municate the increasingly critical fuel situa-tion to the controllers who handled the flight.(captain, communications/first officer, com-munications)

11. The first officer, who made all recordedtransmissions to U.S. controllers, was suffi-ciently proficient in English to be understoodby air traffic control personnel.

12. The first officer incorrectly assumed thathis request for priority handling by air trafficcontrol had been understood as a request foremergency handling. The captain experienceddifficulties in monitoring communicationsbetween the flight and air traffic control.

(captain, communications/first officer, com-munications)

13. The controllers’ actions in response to AVA052’s requests were proper and responsive toa request for priority handling. They did notunderstand that an emergency situation ex-

isted. (ATC, communications)

14. The first officer, who made allrecorded radio transmissions in En-glish, never used the word “emer-gency,” even when he radioed thattwo engines had flamed out, andhe did not use the appropriatephraseology published in U.S. aero-nautical publications to communi-cate to air traffic control the flight’sminimum fuel status. (first officer,communications)

15. The weather conditions at JFK were worsethan forecast. (weather/ATC, communications)

16. The captain did not fly the ILS approach ina stabilized manner, which led to a seriousdeviation below the glideslope and to his ini-tiation of a go-around. (captain, proceduralbehavior)

17. A windshear on the approach path may havecontributed to the captain’s poor performanceon the ILS approach. Although other flights suc-cessfully completed the approach through thesame wind conditions, the captain’s performanceon the approach was probably degraded by fa-tigue after the long flight and by his reliance onraw glideslope position data rather than on au-topilot or flight director guidance. (captain, physi-ological/airline maintenance, organizationaloversight/captain, decision making)

18. The FAA traffic management programs failedto effectively manage the traffic volume at JFK,leading to excessive delays and airborne hold-ings, including more than one hour for AVA052. ( FAA, organizational oversight)

19. The FAA’s traffic management programsfor JFK did not adequately account for over-seas arrivals and missed approaches at JFK.(FAA, organizational oversight)

The firstofficer … neverused the word

“emergency” … .


20. Cabin crew members and passengers werenot warned of the impending crash landing,which may have contributed to the severity ofthe injuries sustained. (captain, proceduralbehavior/second officer, procedural behavior/senior flight attendant, procedural behavior)

21. The serious and fatal injuries were the re-sult of blunt force trauma because of high ver-tical and longitudinal deceleration forces dur-ing the impact sequence.

22. The emergency evacuation slides were inop-erative because of the lack of appropriate floorattachment hardware. (DAAC, organizationaloversight/maintenance, organizational oversight/senior flight attendant, procedural behavior)

23. There were no shoulder harnesses or iner-tia reels installed on captain’s and first officer’sseats. (company, organizational oversight)

24. The response of fire and rescue personnelwas timely and effective, and the use of heli-copters by the Nassau County Police Depart-ment probably saved lives.

Human Factors Were Significant

This accident investigation is a human perfor-mance investigator ’s cornucopia. A scan of the

NTSB’s 24 findings uncovers 17 findings thatdirectly or indirectly identify 31 individualhuman performance errors by the flight crew,air traffic controllers, weather services, gov-ernment oversight agencies, company dispatch,maintenance and management (Table 1).

The parties to the investigation, especially Avi-anca Airlines, were all very cooperative dur-ing the year-long investigation. A public hear-ing held in Long Island, N.Y., in June 1990,brought out many of the international airlinepilots’ and human factors research community’sassessments of the problems highlighted inthis accident. However, because the flight crewdid not survive the accident, an in-depth hu-man factors investigation was not possible tohelp explain why the flight crew’s decision-making process broke down. Stress and fa-tigue are illusive causal factors based on in-tuitive information and the experiences of thepast. How the flight crew got into this tragicsituation and what was happening on the groundare not likely to be fully understood.

Recommendations RevealConcerns, Offer Solutions

The NTSB made several recommendations asa result of this accident investigation, both tothe FAA and to the DAAC of Colombia.

Table 1Summary of Human Performance Errors

Flight Communi- Procedural Physio- Decision OrganizationPerson (Total) Planning cations Behavior logical Making Oversight

Capt (10) 4 2 2 1 1F/O (4) 4F/E (1) 1Sen F/A (2) 2Dir Maint(2) 2Dir Ops (2) 2Dispatch (4) 4DAAC (2) 2ATC Cont (1) 1Weather (1) 1FAA Mgt (2) 2

TOTALS (31) 8 8 5 1 1 8


Recommendations to the FAA

• Develop in cooperation with the Inter-national Civil Aviation Organization(ICAO) a standardized glossary of defi-nitions, terms, words, and phrases tobe used that are clearly understandableto both pilots and air traffic controllersregarding minimum and emergency fuelcommunications.

• Conduct a comprehensive study of thecentral flow control facility and the trafficmanagement system, by the agency’sOffice of Safety/Quality Assurance, todetermine the effectiveness and appro-priateness of training, responsibilities,procedures and methods of applicationfor the traffic management system.

• Require that transport category airplaneflight manuals include procedures speci-fying minimum fuel values for variousphases of airline flights at which a landingshould not be delayed and when emer-gency handling by ATC should be re-quested. The manual requirement andassociated amendments to regulationsand procedures should include criteriafor when ATC must be notified that theairplane must be en route to its desti-nation or alternate airport via routinehandling, and when emergency handlingis required.

• Incorporate into air route traffic con-trol centers equipment to provide a re-corded broadcast of traffic managementinformation that can be monitored byall aircraft within each center’s bound-aries to provide pilots with early indi-cations of potential delays en route.

• Prior to the release of the final accidentreport, the NTSB had made three ear-lier safety recommendations to the FAA.These concerned notifying all domesticand foreign air carriers to be familiarwith the U.S. National Airspace Sys-tem and its rules and procedures, andfor air traffic controllers to request clari-fication whenever a possible emergency

situation is occurring and offer assis-tance. [These recommendations werepublished by Flight Safety Foundation,Accident Prevention Bulletin, April 1990.]

Recommendations to the DAAC, Colombia

• Review policies, procedures, trainingand oversight activity to ensure thatadequate emphasis is being placed onthe dual responsibility that flight dis-patchers and flight crews have in keepingeach other informed of events and situ-ations that differ from those mutuallyagreed upon in the dispatch release.

• Require that Avianca Airlines incorpo-rate cockpit resource management (CRM)and line oriented flight training (LOFT)concepts into its flight crew trainingprogram.

Report Included Dissents

In a dissenting statement, NTSB Member JimBurnett supported the causes and recommen-dations, but listed four specific unsatisfactoryservices provided to AVA 052 in holding, weatherinformation, passing on the fuel situation toother controllers and updating the JFK ATIS.He further stated that the FAA allowed moreaircraft into the system than it could safelyhandle.

Member Christopher Hart stated that the Avi-anca crew should have known to use the words“Mayday” or “emergency” to communicate theirdangerous situation to ATC and that a lack ofstandardized terminology is not a contribut-ing factor.

Also, the DAAC stated that there were manyinadequacies and ambiguities on the part ofU.S. ATC procedures that misled the Aviancaflight crew into thinking they were receivingspecial handling when they were not. It statedthat they were given holding after telling ATCthey could not make their alternate and weregiven a normal long landing pattern after tell-ing ATC they were running out of fuel. DAACalso stated that EFC times should include in-


Aviation Statistics

Worldwide Passenger TrafficDeclines

The Persian Gulf War and the threat of greatlyincreased terrorism influenced a slowdown inworldwide passenger air traffic in 1991. When

Worldwide Passenger Traffic andAir Carrier Safety

Calendar Year 1991by

Shung C. HuangStatistical Consultant

the hostilities ended in the spring of 1991, itwas expected by most industry observers thatthere would be a resurgence in worldwide airtravel. However, even the quick end of thewar, followed by peace negotiations betweenthe Arab States and Israel, failed to stimulatea favorable environment for worldwide pas-

formation on when a pilot can expect to land.The agency said ATC should require an activeflight following system with landing delay in-formation for international flights not subjectto ground holds. �

About the Author

Capt. Thomas A. Duke is a free-lance aviationsafety writer. He previously was with the Safety

Studies Division of the U.S. National TransportationSafety Board (NTSB). He is a former captain withIndependent Air and flew international chartersin the Boeing 707.

Duke spent 30 years in the U.S. Air Force. He wasdirector of safety of the Air Force Reserve, and manageda worldwide investigative and accident preventionprogram that won several awards. He has more than11,400 hours of military and airline flying and morethan 16 years of active safety management.


senger traffic. On the contrary, the aftereffectsof the war, including the political stalemate inthe Gulf area, the standstill in the world eco-nomic recovery and continuing concerns aboutthe potential effects of terrorist attacks uponthe safety of flight continues a severe declinein both international and U.S. domestic airtravel.

As a result of the negative forces, the world-wide air carrier industry experienced its firstdecline in passenger traffic in two decades dur-ing 1991. Preliminary estimates from the Inter-national Civil Aviation Organization (ICAO)indicate that worldwide total passenger andcargo ton-kilometer figures will show a declineof four percentage points in 1991 compared tothe previous year. The annual distribution ofworldwide airline passenger-kilometers for thepast 10 years is shown in Figure 1.

Decline in U.S. Passenger Traffic

The decline of passenger traffic in the UnitedStates, which accounts for more than 40 per-cent of worldwide passenger traffic, was evenmore severe than the international decline. In1991, the number of passengers carried by U.S.

airlines for the first 11 months dropped to 418million from 436 million in 1990, a decline of4.5 percent; the passenger-miles flown droppedfrom 433 billion to 422 billion, a reduction of2.7 percent. The monthly comparison of pas-sengers carried and passenger-miles flown byU.S. airlines for 1990 and 1991 is shown inTable 1. Note that during the 11-month periodfor which information is available, in not a

Table 1Passengers Carried and Passenger-miles Performed

U.S. Airline all OperationsScheduled and Non-scheduled Services

1990 vs. 1991

Passengers Carried (000) Passenger-miles (Million)Month 1990 1991 Change 1990 1991 Change

January 35,548 34,897 -1.8 35,153 34,828 -.09February 34,790 32,063 -7.8 32,965 29,610 -10.2March 41,996 37,637 -10.4 39,993 36,142 -9.6April 39,560 37,803 -4.4 37,987 36,951 -2.7May 39,492 38,623 -2.2 38,419 38,789 +1.0June 42,419 40,334 -4.9 42,819 41,675 -2.7July 43,618 42,885 -1.7 45,770 45,269 -1.1August 46,316 44,677 -3.5 48,763 48,104 -1.4September 37,073 36,010 -2.8 38,173 37,578 -1.6October 39,599 38,426 -3.2 39,051 38,925 -0.3November 37,525 35,614 -5.0 35,699 34,367 -2.7December 37,330 not available 37,331 not availableJanuary-November Total 436,525 418,971 4.5 433,792 422,238 -2.7

Source: Air Carrier Traffic Statistics Monthly, Calendar Year 1990 and 1991 Research and Special ProgramsAdministration, U.S. Department of Transportation.

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

2000000

Year

Wo

rld

wid

e P

asse

ng

ers-

Kiil

om

eter

s (M

illio

n)

Source: ICAO

Passenger-kilometers Performed byWorldwide Airlines

Calendar Year 1881-1991

Figure 1

Wo

rld

wid

e P

as

se

ng

ers

-kil

om

ete

rs (

Mil

lio

n)


Table 2U.S. Accidents, Fatalities and Rates

Air Carriers and General Aviation 1991(Preliminary Data)

Accident RatesPer 100,000 Per 100,000

Accidents Total Aircraft Aircraft Hours DeparturesTotal Fatal Fatalities Hours Flown Departures Total Fatal Total Fatal

Air Carriers OperatingUnder 14 CFR 121

Scheduled 26 4 62# 11,250,000 7,500,000 0.231 0.036 0.347 0.053 Nonscheduled 1 0 0 580,000 270,000 0.172 0 0.370 0

Air Carriers OperatingUnder 14 CFR 135

Scheduled 22 8 99# 2,100,000 2,700,000 1.048 0.381 0.815 0.296 Nonscheduled* 84 26 69 3,270,000 n/a 2.57 0.80 n/a n/a

General Aviation+ 2,143 414 746 30,760,000 n/a 6.90 1.35 n/a n/a

Exposure data estimate source: U.S. Federal Aviation Administration (FAA).

# Both of these fatality totals include the 12 persons killed aboard a Skywest commuter aircraft (Scheduled 14 CFR 135)and the 22 persons killed aboard the USAir airliner (Scheduled 14 CFR 121) after the two aircraft collided.

* Accidents on non-U.S. soil and in non-U.S. waters are excluded.

+ Includes accidents involving U.S. registered civil aircraft flown under rules other than 14 CFR 121 and 14 CFR 135.Accidents on non-U.S. and in non-U.S. waters are excluded.

n/a Data not available.

Worldwide Airline Fatal Accidents and Fatalities

Source: FSF Flight Safety Digest 1981-1990

Figure 2

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

0

5

10

15

20

25

30

Year

Fat

al A

ccid

ents

Ten-yearaverage

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Year

Fat

alit

ies

Ten-yearaverage


single month in 1991 was the passenger traffichigher than that in the corresponding monthof 1990.

Air Traffic Declines inThe Former Soviet Union

The Mideast crisis might not have caused sig-nificant negative effects on former-Soviet airpassenger traffic, but news reports have notedthat air passenger traffic in 1991 worsened ingrim parallel with the deterioration of U.S.S.R.political and economic systems during the tran-sition to the Commonwealth of IndependentStates (CIS). As a result of a decreasing supplyof fuel from the state energy monopoly, anestimated 40 percent of Aeroflot planes weregrounded at one point. In late December 1990,the transport minister reported that Aeroflot

operations could be off by as much as 50 per-cent for that month.

Airline Safety FiguresReflect A Good Year

During 1991, worldwide airlines operating largeaircraft were involved in 13 fatal accidentsthat accounted for 760 fatalities. Fourteen jettransport aircraft used by worldwide airlineswere totally destroyed. Figure 2 shows the an-nual numbers of fatal accidents and fatalitiesinvolving worldwide airlines for the period1981-1991. It shows that in 1991 worldwideairlines recorded fewer fatal accidents and fa-talities than those in most prior years, andfewer than the average of the past 10 years. Tobe exact, the average for fatal accidents is 20and that for fatalities is 989 as indicated on

Table 3Worldwide Airline Fatal Accidents and Jet Transport Hull-losses

Calendar Year 1991

Date Location Aircraft Damage Fatalities Phase Remark

1/2 Los Angeles, Calif., U.S. B-737 Destroyed 34 Takeoff Collided with other aircraft onrunway after landing

2/17 Cleveland, Ohio, U.S. DC-9 Destroyed 2 Takeoff Crashed out of control2/20 Puerto Williams, Chile BAe 146 Destroyed 20 Landing Overran the runway and crashed

into sea3/3 Colorado Springs, Colo., U.S. B-737 Destroyed 25 Approach Crashed on approach loss of

control3/5 Trujillo, Venezuela DC-9 Destroyed 43 Approach Crashed into high ground in low

visibility3/12 New York, N.Y., U.S. DC-8 Destroyed none Takeoff Aborted takeoff, rupturing fuel

line. Fire after impact.3/23 Tashkent, Russia An-24 Destroyed 31 Landing Veered off runway and crashed

into concrete blocks5/23 St. Petersburg, Russia TU-154 Destroyed 10 Landing Crashed on Landing5/26 Suphan Buri, Thailand B-767 Destroyed 223 Cruise Loss of control; malfunction of

thrust-reversers6/26 Sohoto, Nigeria BAC 1-11 Destroyed 3 Landing Crashed on emergency landing

in adverse weather7/11 Makhackala Yak-40 Destroyed 34 Approach Crashed into high ground on

approach8/16 Imphal, India B-737 Destroyed 69 Approach Crashed on approach11/7 Jeddah, Saudi Arabia DC-8 Destroyed 261 Takeoff Crashed on emergency landing

shortly after takeoff12/7 Tripoli, Libya B-707 Destroyed none Takeoff Crashed on takeoff run12/27 Stockholm, Sweden MD-81 Destroyed none Takeoff Engine failure/crashed on

emergency landing12/29 Shienchu, Taiwan B-747 Destroyed 5 Approach Crashed on emergency landing

due to engine failure

Source: News reports compiled by author.


Figure 2 by horizontal lines. Note that the an-nual distribution of fatal accident and fatali-ties appears to be random.

U.S. Airline Safety Figures Are Mixed

In the United States, the National Transpor-tation Safety Board (NTSB) reported that U.S.airlines operating large aircraft in 1991 wereinvolved in 27 accidents, four of them fatalthat resulted in 62 fatalities. This representstwo fatal accidents fewer than, but 23 fatali-ties more than, those recorded in 1990. TheNTSB also reported that commuter air carri-ers were involved in 22 accidents, eight ofwhich were fatal, that accounted for 99 fa-talities. In terms of fatalities, 1991 was theworst safety year ever for commuter air car-riers. The NTSB accident statistics for U.S.air carriers, commuter air carriers, air taxisand general aviation for 1991 are shown inTable 2.

Former-Soviet Airline SafetyStatistics Show Short-term Decline

Because not all aviation accident informationinvolving former-Soviet airlines is reported,complete statistics are difficult to obtain. Ac-cording to news reports, aviation safety in theSoviet Union eroded badly during the pastthree years. The news media has reported thatAeroflot, the ex-U.S.S.R. state airline, was in-volved in 36 accidents in 1991 that accountedfor 252 fatalities compared to 27 fatal acci-dents and 194 fatalities in 1990.

Worldwide Airline FatalAccidents Listed for 1991

Table 3 is a listing of fatal accidents and jettransport hull-losses involving worldwide air-lines that operated large aircraft during 1991.It includes three fatal Russian accidents of the36 accidents reported by Aeroflot. Informa-tion in table 3 is preliminary. �

Reference

Updated Reference Materials (Advisory Circulars, U.S. FAA):

Numbers(s) Mo/Yr Subject43-4A July 1991 Corrosion Control for Aircraft (Cancels AC 43-4 dated

May 1973)150/5200-30A Oct 1991 Airport Winter Safety and Operations (Cancels AC 150/5200-

30 dated April 1988)150/5200-30A Nov 1991 Change 1 to Airport Winter Safety and Operations150/5345-28D Nov 1991 Change 1 to Precision Approach Path Indicator (PAPI) Systems150/5345-42C Oct 1991 Change 1 to Specifications for Airport Light Bases, Transformer

Housings, Junction Boxes, and Accessories

Reports Received at FSFJerry Lederer Aviation Safety Library


National Transportation Safety Board (U.S.) Safety Recommendations:

Number(s) Mo/Da/Yr SubjectA-91-104/121 12/03/91 USAir Boeing 737-300 and Skywest Fairchild Metro-liner colli-

sion, Los Angeles, California, U.S., February 1, 1991

New Reference Materials:

Advisory Circular 25-17, 11/25/91, Announce-ment of Availability of Advisory Circular 25-17, Transport Airplane Cabin Interiors Crash-worthiness Handbook. — Washington, DC :U.S. Federal Aviation Administration, 1991.1 p.

Summary: Advisory Circular 25-17 providesacceptable certification methods, but not nec-essarily the only acceptable methods, of dem-onstrating compliance with the crashworthi-ness requirements of Part 25 of the FederalAviation Regulations (FAR) for transport cat-egory airplanes. This announcement pro-vides notice that Advisory Circular 25-17, dateJuly 15, 1991, is available only as a sale docu-ment from the Superintendent of Documents,and is not available from the U.S. FederalAviation Administration. Copies may be or-dered from: Superintendent of Documents,U.S. Government Printing Office, Washing-ton, D.C. 20402. Stock Number 050-007-00915-1. The cost of AC 25-17 is $11.00 (U.S.)for U.S. orders. Orders for mailing to for-eign countries mustinclude an additional $2.75(U.S.).

Advisory Circular 120-55, 10/23/91, Air Car-rier Operational Approval and Use of TCASII. — Washington, DC : U.S. Federal AviationAdministration, 1991. 31 p. in various pagings.

Summary: This Advisory Circular (AC) pro-vides an acceptable means, but not the onlymeans, to address Traffic Alert and CollisionAvoidance System (TCAS) issues related toinstallation and use of TCAS II regarding com-pliance with Federal Aviation Regulations (FAR)Parts 121, 125, and 129 requirements for aircarriers. [Purpose]

Reports

FAA Registry Systems: Key Steps Need to be Per-formed Before Modernization Proceeds. Report tothe Chairman, Permanent Subcommittee onInvestigations, Committee on GovernmentalAffairs, U.S. Senate/ United States GeneralAccounting Office. — Washington, D.C. : Gen-eral Accounting Office**, [1991]. Report GAO/IMTEC-91-29. 13 p. ; 28 cm.

Key Words1. United States — Federal Aviation Admin-

istration.2. Airplanes — Inspection — United States.3. Air Pilots — Drug Use — United States.4. Air Pilots — Registers — United States.

Summary: GAO reports on the Federal Avia-tion Administration’s (FAA) modernization plansfor its airmen and aircraft registry systems. TheAnti-Drug Abuse Act of 1988 requires changesto these systems to make them more effectivein serving the needs of law enforcement agen-cies involved in aviation drug interdictions andinvestigations. GAO found that FAA has notadequately defined users’ needs for the sys-tem, leaving FAA with little assurance that ithas selected the most appropriate technologi-cal solution, and increasing the risk of cost over-runs and schedule delays. At the conclusion ofthe GAO review, FAA officials stated that theyplanned to correct the deficiencies GAO identi-fied. [Modified Results]

The Prevalence of Aphakia in the Civil AirmanPopulation. Final Report/Van B. Nakagawara,Faredoon K. Loochan, Kathryn J. Wood (CivilAeromedical Institute). — Washington, D.C.:Federal Aviation Administration, Office of Avia-tion Medicine; Springfield, Va., U.S.: Avail-


able through NTIS*, [1991]. Report No. DOT/FAA/AM-91-14. v, 13 p.: charts; 28 cm.

Key Words1. Air Pilots — Certification — United States.2. Air Pilots — Medical Examinations — United

States.3. Aphakia.4. Eye — Abnormalities.

Summary: Aphakia has become increasinglyprevalent in the civil airman population. TheFAA allows civilian airmen with aphakia tofly with waivered certificates. The increasedapplication and modification of surgical pro-cedures for cataract extraction, coupled withpossible visual complications from these pro-cedures in flight operations, strongly suggestscontinued specialized aeromedical certificationand clinical research review. This study ana-lyzes the distribution of aphakia in the civilairman population by type (unilateral, bilat-eral), class of airman medical certificate, andgender for a four-year period (1982-1985). [Modi-fied author abstract]

Selection of Air Traffic Controllers: Complexity,Requirements, and Public Interest. Final Report/edited by Hilda Wing (Federal AviationAdministration) and Carol A. Manning (CivilAeromedical Institute). — Washington, D.C.:United States. Federal Aviation Administra-t i o n , O f f i c e o f Av i a t i o n M e d i c i n e ;Springfield, Va., U.S.: Available through NTIS*,1991. Report DOT/FAA/AM-91/9. v, 38 p.:ill.; 28 cm.

Key Words1. Air Traffic Controllers — Selection and

Appointment — United States.

Contents: Overview of National Airspace Hu-man Resource Management Planning Process/Earl Pence (Fu Associates) and Shelly A. Tho-mas — Employing Air Traffic Controllers/JayC. Aul (FAA) — Procedures for Selection ofAir Traffic Control Specialists/Carol A. Man-ning (Civil Aeromedical Institute) — Evalua-tion Issues in the Selection of Air Traffic Con-trollers/Hilda Wing and Darlene M. Olson (FAA)— Discussion of Selection of Air Traffic Con-trollers: Complexity, Requirements, and thePublic Interest/Phillip L. Ackerman (Univer-sity of Minnesota).

Summary: The essays in this report representpresentations made at the 98th Annual Con-vention of the American Psychological Asso-ciation, August 10-14, 1990, in Boston, Mass.,U.S. The presentations address the diverseprocess of valid selection for the highly de-manding occupation of air traffic control spe-cialists.

*U.S. Department of CommerceNational Technical Information Service (NTIS)Springfield, VA 22161 U.S.Telephone: (703) 487-4780

**U.S. General Accounting Office (GAO)Post Office Box 6012Gaithersburg, MD 20877 U.S.Telephone: (202) 275-6241


Accident/Incident Briefs

This information is intended to provide an aware-ness of problem areas through which such occur-rences may be prevented in the future. Accident/incident briefs are based upon preliminary infor-mation from government agencies, aviation orga-nizations, press information and other sources. Thisinformation may not be accurate.

Hurried DepartureGoes Nowhere

Boeing 707: Moderate damage to fuselage. Noinjuries.

The cargo-configured jetliner was parked ad-jacent to a fixed cargo handling system de-signed for use with that type aircraft. It hadbeen parked there at 1115 hours for unloadingand reloading prior to a scheduled 1330 de-parture.

The unloading of the cargo was accomplishedusing a fixed, high-lift pallet loader on the leftside of the aircraft that is able to be extendedor raised to be aligned with the cargo door ofthe aircraft. However, loading was delayedunexpectedly and the scheduled departure slotof 1330 was extended two hours to 1530. Al-though the aircraft was loaded in time for therevised departure, the contracted loading crewmembers reached the end of their shift a shorttime before the new departure time and theydeparted, leaving the tug driver as the onlyground crew member with the aircraft. Theflight crew was already aboard.

The tug driver retracted and lowered the loadingplatform and positioned the tug for the pushback.

However, the close proximity of the cargo plat-form on the aircraft’s left, the cargo buildingin front and a walkway support structure toits right resulted in tight quarters, with scrapemarks from previous incidents evident on thecargo building. When the tug driver attemptedto connect the towbar, he noticed that theaircraft’s nosewheels were slightly to his rightof the centerline painted on the ramp, and atan angle to it, which combined with the close-ness of adjacent structures, would make anyextra maneuvering of the aircraft very diffi-cult. He left to telephone for help from thenext ground crew shift because he was awarethat there should have been three other groundcrew members available to assist him with thepushback.

While the tug driver was away, the aircraftoperator’s cargo manager arrived to check theaircraft’s documentation. He extended the cargoplatform to within 18 inches of the fuselage toboard it but, on leaving, did not retract orlower the platform, because he saw a manconnect the air start unit and then sit on thetug and assumed he would retract the loadingplatform.

The captain was anxious to meet the reviseddeparture time that was rapidly approaching,so he requested engine start and pushback clear-ance even though the next shift of ground supportpersonnel had not arrived. One of the carrier ’sground technicians assisted with engine startand removal of the ground power units andcommunicated with the pilot during start andpushback. Neither the technician nor the tugdriver accomplished a pre-pushback inspec-tion of the ramp.

The pushback was begun without the full groundcrew and with no attempt to control vehiculartraffic on the service roads that were locatedto the rear and the side of the aircraft. Afterthe aircraft had moved approximately five feet,the captain sensed something was not rightand ordered the pushback stopped. A check

Air CarrierAir Carrier


of the fuselage revealed that the aircraft hadstruck the protruding cargo loading platform,which had not been retracted after the company’scargo manager left the aircraft.

The aircraft was out of service for 19 dayswhile repairs were effected.

Three AssumptionsLead to Trouble

Airbus A310: Substantial damage. No injuries.

Boeing 757: Substantial damage. No injuries.

The Boeing 757 had taxied for a scheduleddeparture, but a technical fault had been de-tected and it had been cleared back to its park-ing stand by air traffic control (ATC) to havemaintenance attend to the problem prior todeparture.

The Airbus was being prepared for departurefrom a parking stand on the opposite side of ataxiway from the parking stand to which theBoeing 757 was returning. Parking was nose-in for both aircraft, with pushback being pro-vided by tugs.

The ground controller observed that the Boe-ing 757 had passed behind the still parkedAirbus, turned onto the centerline of its park-ing stand and was moving forward into itsparking position. The parking stands were ona cul-de-sac to which the controllers had lim-ited vision and having seen the returning air-craft moving into its parking stand, the con-troller assumed that the parking maneuver wouldbe completed normally. Therefore, he issueda pushback clearance to the Airbus which wasready for departure.

The Airbus began its pushback, supervised byone ground engineer positioned on the leftside of the aircraft who was in interphone contactwith the cockpit crew. The only other groundcrew member was the tug driver, who hadvery limited vision to the rear of the aircraft.Both ground crew members had observed theBoeing 757 pass behind their aircraft and turninto the centerline of its parking stand. Both

assumed, as had the ATC controller, that theBoeing would complete its parking procedurenormally.

During pushback of the Airbus, the pilot coor-dinated startup of the right engine with theground engineer who then had to divide hisattention between observing proper engine fanrotation on the right side of the airplane andmonitoring the left wingtip for clearance fromthe Boeing. (The Airbus was being pushed backin a turn to its right, so the left wingtip wouldpass behind the tail of the Boeing.)

As the Airbus exited its parking stand, theground engineer observed that the left wing-tip was swinging around toward the tail of theBoeing that had unexpectedly stopped part ofthe way out of the parking stand. He advisedthe flight deck over the intercom and tried tosignal the tug driver, whose attention was fo-cused on correctly positioning the aircraft’snosewheel.

The left wingtip of the Airbus collided withthe underside of the Boeing’s tailplane andrear right fuselage, causing substantial dam-age to that aircraft and damage to the wingtipand trailing edge of the Airbus. There was nofire and passengers of the aircraft were de-planed without further incident by use of mo-bile stairways.

Investigation revealed that as the Boeing be-gan to enter its parking stand and had beenassumed by ATC and the Airbus ground crewto be completing its parking normally, the flightcrew realized that the entry guidance systemwas not illuminated and decided to stop theaircraft until the parking guidance system wasilluminated or a ground crew member arrivedto provide guidance. The tail of the aircraftwas protruding into the taxiway by approxi-mately 69 feet. Because of heavy radio traffic,the flight crew was unable to inform ATC ofits predicament immediately. The aircraft wasstopped only briefly until the call was made;the Airbus wingtip impacted the Boeing whilethe captain was transmitting his situation.

Although the company had been advised thatthe Boeing was returning to the parking stand


after the parking guidance lights had been au-tomatically activated by a timer, the lack ofavailable dispatchers at the time caused a de-lay in assigning someone to meet the aircraft.The collision had occurred by the time thiswas accomplished.

Press on RegardlessIs Not Prudent Practice

de Havilland DHC-6 Twin Otter: Substantial damage.One serious injury.

The pilot elected to make a short-field takeofffrom the 2,400-foot gravel runway. Passen-gers included four occupants in addition tothe pilot and one large dog. The weather wasclear and cold with visibility more than 15miles.

The pilot lost directional control shortly afterthe takeoff run began. The aircraft veered tothe right and then swung back across the run-way to the left edge along which the pilotattempted to continue the takeoff. The air-craft lifted off after a ground run of approxi-mately 1,200 feet but the right wing droppedand scraped the ground, after which it toucheddown on the main gear with the tail skid drag-ging on the surface. Another change in direc-tion aimed the aircraft to the right again, andit left the runway at an angle of 35 degreesand traveled through brush along the side ofthe runway.

The pilot continued the attempt to becomeairborne and the aircraft lifted off again. Theleft wing collided with the roof of a woodenshed and continued flying a few feet abovethe ground. After continuing for approximately400 feet, the aircraft flew over a 50-foot em-bankment, then rolled to the left and droppedto the ground where it impacted first on the

left wing. First the left, then the right wing,broke free from the fuselage. There was nofire. The occupants all evacuated the wreck-age without assistance, and the only reportedinjury was to a passenger who had been in theright cockpit seat.

The investigation revealed that the trail madeby the nosewheel indicated that it had notbeen centered at the start of the takeoff roll.The pattern of runway dirt thrown up by thewheel indicated misuse of nosewheel steer-ing, which can lead to loss of directional con-trol. There had been no attempt to abort thetakeoff either when directional control wasinitially lost or when the right wing hit theground shortly after the first liftoff. Scrapemarks made by the tail skid indicated that theaircraft was forced to lift off at an airspeedthat was too low to sustain flight and in adirection not aligned with the runway.

The pilot was cited for misuse of nosewheelsteering early in the takeoff sequence and fornot aborting the takeoff.

Open Drain ValveBrings Aircraft Down

McDonnell Douglas DC-6: Aircraft destroyed. Fatalinjuries to three.

The four-engine aircraft was forced to makean emergency descent because of fuel exhaus-tion. The late afternoon cargo flight was oninstrument flight rules (IFR) in visual meteo-rological conditions (VMC). One propeller wasturning under power while the other threewere windmilling as the aircraft neared theground. On landing, the main gear struck thetop of a levee causing the right wing to hit theground below the levee. The aircraft brokeapart and the wreckage came to rest in a drainagecanal. The three crew members were fatallyinjured in the accident.

The aircraft had departed with seven hours offuel, 2.7 hours of which had been lost because,according to the accident report, there was anopen drain valve discovered in the wreckageinside the number four engine nacelle. Inves-

Air Taxi/CommuterAir TaxiCommuter


tigators estimated that the valve had been openfor an extended time, but no ground person-nel reported having seen fuel draining from itprior to the flight.

Engine StopsDuring Taxiing

Beechcraft B55A Baron: Substantial damage. Noinjuries.

The pilot, with one passenger aboard, had landedafter an international flight and had clearedcustoms. The control tower cleared the pilotto taxi from the customs parking area to aparking area elsewhere on the airport.

The final portion of the taxi route to the desig-nated parking area required the pilot to nego-tiate a narrow taxiway that sloped downhilland had vehicles and aircraft parked closelyon both sides. Wind speed was calm and thetaxiway was dry. Witnesses reported that theaircraft’s taxi speed was faster than normalfor the prevailing conditions but the pilot saidhe was taxiing very slowly.

While the aircraft was travelling on the down-ward sloping portion of the narrow taxiway,the right engine stopped but because boththrottles were closed, there was no thrust im-balance to make the pilot aware that an enginehad ceased operation. At the bottom of theslope, however, the pilot noticed the station-ary right propeller as the thrust from the oper-ating left engine began to veer the aircraft tothe right. Application of left rudder and brakehad no effect and the aircraft’s right wing passedover the fronts of parked automobiles and struckthe roof of a van. The impact caused the air-craft to swing sharply to the right where it

collided with a parked aircraft which it pushedback into an embankment.

There was no fire and the pilot and passengerdeplaned through the cabin door without in-jury. The aircraft sustained damage to the rightwing, nose cowling, left propeller and leftengine.

Rushed Pilot LosesTrack of Altitude

Beechcraft B55: Substantial damage. Fatal inju-ries to one.

The aircraft was flying under instrument flightrules (IFR) at night on approach to its desti-nation. There were one crew member and onepassenger aboard. The pilot had listened tothe automatic terminal information service(ATIS) and learned that the nondirectionalbeacon (NDB) approach to runway 21 was inuse.

As the aircraft approached the NDB, the pilotwas asked by the air traffic controller if hewanted the localizer approach to runway 15instead of the NDB approach. The pilot chosethe localizer approach and was given vectorsto intercept it. As the pilot intercepted thelocalizer course, he was asked by air trafficcontrol (ATC) whether he was inside or out-side the NDB fix. The pilot looked at thedistance measuring equipment (DME) but wasunable to read it because of the glare from aflashlight the passenger was using to preparecharts for landing at an alternate airport if anovershoot was required.

The pilot then looked at the course deflectionindicator (CDI) of the number one very highfrequency omnidirectional range (VOR) receiverto find his position on the localizer. The needleshowed a full deflection to the left, and thepilot replied that he was inside the fix. Therewas no further contact with the pilot and asearch was initiated minutes later. The aircraftwas located three and one half hours later,five nautical miles from the threshold of therunway and one-fifth nautical mile west of theNDB fix.

Corporate ExecutiveCorporateExecutive


The accident report states that the pilot hadprepared himself for an NDB approach. Whilethe pilot was being vectored for the localizerapproach to runway 15, he was also selectingand analyzing the approach plates, slowingthe aircraft, descending and lowering the flapsand gear. The report states that the speed ofthe aircraft rushed the pilot. He entered 79degrees into the omni-bearing selector of theVOR, instead of 75 degrees. When ATC askedthe pilot if he was past the NDB fix, the pilotstated incorrectly that he was.

The pilot would be expected to start his de-scent after crossing the fix from 2,000 feet abovesea level (asl); the minimum descent altitudeis 1,080 feet asl. However, the report states,because the aircraft was off course to the right,the pilot was probably concentrating on re-turning to the localizer and was inattentive toaltitude. The aircraft flew over a golf coursewhich has an elevation of 920 feet asl andstruck the trees.

The aircraft was destroyed, the pilot was seri-ously injured and the passenger was fatallyinjured. The pilot was cited for being unsureof his position on the approach; he was un-aware that he had descended too low for theapproach until the aircraft struck the trees.

Low Clouds, Poor Visibility,Disorientation, No Flight Plan

Produce Expected Result

Cessna 175: Aircraft destroyed. Fatal injuries toone.

The pilot arrived at the closed small airportslightly prior to 0800 hours on the early springday. He had been visiting the area for three

days, and took off without having filed a flightplan; a nearby resident heard the aircraft de-part and expressed surprise that someone wasflying in the low clouds and poor visibility.The pilot was rated for instrument flight.

Approximately an hour into the flight the pi-lot made his first radio contact, which was toan air traffic control (ATC) facility reportingthat he was IMC (in instrument meteorologi-cal conditions) without flight information. Hewas given local weather conditions that in-cluded rain, 5/8 cloud coverage at 600 feetand overcast at 800 feet. He was within ap-proximately 30 miles of his intended destina-tion and switched to the ATC unit serving thatarea for airport and weather information, whichwas consistent with the previous weather re-port. There was a one-degree temperature-dewpoint spread.

The pilot was given a clearance and performeda VOR approach. He reported that the aircrafthad made the turn to base leg as called for bythe procedure. ATC requested that the pilotreport when he had the airport in sight andthen enter a downwind leg, and the pilot ac-knowledged. The pilot was advised that thecloud base at 600 feet had become overcastand reported that he could see the ground butnot the airport.

A pilot on the ground reported sighting theaircraft between gaps in the clouds northwestof the airport at a height he estimated to bebetween 200 and 300 feet above the ground.ATC advised the pilot of his location and thatthe aircraft was headed for high ground. Thepilot acknowledged and advised he was mak-ing a missed approach, next reporting he waspassing through 800 feet.

Shortly thereafter, when ATC requested hisintentions, the pilot reported that he had amajor problem, that he was suffering spatialdisorientation and was “in a loop.” This wasthe last radio transmission from the aircraft.Rescue services were alerted and a helicopterthat backtracked the last known course of theaircraft found the wreckage of the aircraft in afield less than 20 minutes after the final radiotransmission — the pilot had been killed.

Other GeneralAviation

OtherGeneralAviation


A radar plot of the approach revealed that theaircraft had initially arrived over the VOR sta-tion on course but that the approach proce-dure was not flown accurately in either direc-tion or altitude. It had disappeared tempo-rarily from radar coverage at one point whenit was northwest of the airport and subsequentlyfollowed an erratic path and made rapid changesin altitude, consistent with the pilot’s reportof spatial disorientation and perception thatthe aircraft was in a loop.

The aircraft had struck the ground in a nearvertical attitude and at a high airspeed; it wasdemolished on impact and, although little in-formation could be obtained from the wreck-age, no evidence was found of pre-impact prob-lems with the structure or mechanisms. Thedeviation pointer of the VOR system had hada problem but was repaired some time previ-ously.

Aircraft Taxis on its Own

Piper J-3 Cub: Extensive damage. Minor injuriesto one.

The engine of the two-place, tailwheel aircraftwas not equipped with an electric starter andrequired the propeller to be swung by hand tostart it. The passenger for this flight was not apilot, but had flown with the pilot numeroustimes and had been trained by him to assist inthe engine starting procedure to the extent ofholding the control stick back and applyingthe brakes. He had not been briefed, however,on operation of the magnetos or on the opera-tion of the throttle.

The pilot pumped the throttle and set it to thestarting position, switched on the magnetosand went in front of the aircraft to swing thepropeller by hand. The passenger held thecontrol column back and applied brake pres-sure. The engine started on the first swing ofthe propeller, but operated at a much higherrpm than normal.

The passenger was unable to hold the aircraftstationary with the brakes and did not knowhow to reduce the engine power. The aircraft

began to roll down a slope. The main wheelswere stopped by a small ditch and the aircraftnosed over, coming to rest inverted. The pas-senger was able to evacuate with minor inju-ries. The aircraft sustained a broken propellerand other damage to the wing leading edges,fuselage frame, engine cowling air intake andwindshield.

Two Pilots at One TimeResults in Hard Landing

Robinson R22 Beta: Substantial damage. No inju-ries.

The aircraft was en route to a private landingsite. Aboard were the pilot and a passenger,both of whom were private pilots with heli-copter ratings; the passenger was the moreexperienced pilot in this type aircraft.

The pilot decided to make a practice landingin a field prior to arriving at the destinationlanding site. After accomplishing the landingwithout incident, the pilot elected to execute arunning takeoff. The aircraft slewed slightlyto the right during the takeoff. The pilot wasnot alarmed at this and was satisfied that theaircraft was under control; however, the pas-senger considered that the situation warrantedthat he take control. For a short period, bothpilots attempted to fly the aircraft. The pilotstated that he did not hand over control of theaircraft to the passenger.

During the confusion, the aircraft made a hardlanding. The tail boom and cabin structurewere wrinkled and the landing skids splayedoutward. There was no fire and no injurieswere sustained by the occupants who exitedwithout further incident.

RotorcraftRotorcraft


Rocks Hide inLow-lying Mists

Messerchmitt-Bölkow Blohm BK117: Aircraft de-stroyed. Fatal injuries to 10.

The rotorcraft had departed during the earlyevening in visual meteorological conditions(VMC) with a crew of two and eight passen-gers aboard.

During the flight, the weather deterioratedbecause of an approaching typhoon and an

occluded front. The pilot elected to continuethe flight to the destination and, under condi-tions of very little visibility, he descended to avery low altitude. The helicopter collided witha hill covered by fog and mist. The aircraftwas destroyed by the impact and all 10 occu-pants sustained fatal injuries.

Factors cited in the accident included incor-rect pilot decisions by not maintaining VMCconditions after the aircraft encountered re-strictions to vision, and poor monitoring bythe flight service operator. �

Six Hours and 26 Minutes into a Four Hour, 40 Minute Flight

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