What follows is the raw text from a RareAviation.com document available for download. This text can be helpful if you would like to confirm the document contains specific information you are interested in. Title: DC-4 Accidents: Detailed case studies of accidents from 1934 to 1965 Link: https://rareaviation.com/product/dc-4-accident-reports-1934-to-1965 --- RAW TEXT BELOW --- SA-159 File NO. 1-0094 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT 1 Adopted: ISay 19, 1949 Released* Hay 20.1949 ALASKA AIRLINES, SEATTLE WASHINGTON, NOVEMBER 30, 1947 The Accident At 1425*, November 30, 1947, Alaska Airlines1 non-scheduled Flight 009, a C-54 airplane, NC-91009, went off the end of a wet runway at the Seattle-Tacoma Airport, Seattle, Washington, and collided with a moving automobile. Eight of tne 28 occupants of the aircraft and one occupant of the automobile were killed Seventeen occupants of the aircraft suffered injuries. The aircraft was des"croy ed. r History of the Flight Flight 009 departed from Anchorage, Alaska, at 0804, November 27, 194? for Seattle, Washington, with a fueling stop planned at Yakutat, Alaska. The crew consisted of James E. Farris, captain, Richard F. Whitting, first officer, and Reba E. Honk, stewardess. The aircraft carried 26 passengers,** including one infant, 7,755 pounds of freight, and 1,875 gallons of fuel. Total airplane weight at takeoff was reported as 63,000 pounds, which was within the maximum allowable. At 1033, the flight arrived st Yakutat, where it remained 2 days oecause of unfavorable weather, and during this time the aircraft stood m almost continuous ram. Difficulty in starting the engines on the morning of November ^9 was experienced, but once started they operated satisfactorily, and at 0414 the flight departed for Seattle. Alternates were Annette Island and Gustavus, in Alaska, with a fueling stop planned at Port Hardy, British Columbia- *A11 times noted herein are Pacific Standard and based on the 24-hour clock. **0ne of the 26 passengers left the flight at Yakutat. Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com r J v 7 Flight 009 flew to within 15 minutes of Port Hardy, British Columbia which j s approximately 356 miles by airways from Seattle, when the crew J learned that, the weather at Port Hardy had gone below minimums; and that all points farther along the route either were closed or forecasted to close. Moreover, 3 engines were operating roughly, so the flight turned back and landed at Annette Island at 0835. After mechanics there had removed con sjderable water from the ignition harnesses and magnetos on all engines, and had replaced all spark plugs in engine 1, and half of those m engine 2, all engines operated normally The'following morning, November 30, at 1041, Flight 009 departed from Annette for Seattle with Portland, Oregon, being designated as the alternate ; airport. At the time of takeoff all engines appeared to be operating normal!;. and the flight proceeded for approximately the first 1-1/2 hours without difficulty. A Mr. Leslie Greening, a former Ai?sks Airlines traffic agent, occupied the engineer's scat, and then after takeoff s tood behind the copilot. Between 1-1/2 and 2 hours after departure from Annette, Gautam Tarns left his station nnd took a seat in tne passenger cabin. Mr. Greening teen occupied' the right hand or copilots seat while Copilot Whitting handled -he controls from the leit or the pilot's seat. Approximately a half an hour later, nd when ~he aircrrft'was in the vicinity of Gomox, British Columbia, 226 'Ci311 Air Regulation - 42.40 Pilots at controls. In the case of aircraft requiring two or more pilots, ' two pilots must remain at the controls at all times while landing and taking off, and while the aircraft is en route except when the absence of one is necessary in connection with his regular duties or when he is replaced by a person authorized under the provisions of 42.41. 42.41 Admission to pilot compartment. In aircraft having a separate pilot compartment, no person other than a crew member, a cneck pilot, an inspector of the Administrator or a representative of the Board m pursuance of official duty, or a person whose admission is approved by the first pilot, may be admitted ro the pilot compartment. In the latter case, the first pilot must remain at the controls. miles from Seattle, Copilot Witting requested Captain llams to return to rhe cockpit. One hour previously Pan American had landed at CoriOx because of c'dverse weather ahead, and Copilot Mitring desired Captain Farris to make The decision as to whether a landing should be made at Comox or whether the flight snould continue on to Seattle. The flight arrived, over the Seattle radio range station at 3?000 feet on its initial apnroach to the Boeing Airport at 1357. Shortly before Captain Fams had reported to Seattle Sad: o that he had 2 rough engines, but ho nd not declare an emergency. The condition of engine roughness is discussed I ' (below. Weather at B0Cing field, Seattle, Washington, was reported to be k ceiling indefinite 500 foot visibility one mile. An instrument approach for lanaing ^t Boeing Field was made, but not completed because of the low --- y ceiling and visibility, so the fligh+ returned to an altitude of 1,500 feet on the nortnv.es t course of ^he ^cattle radio range. D unng this time * Copilot ^hitting remained m the left seat and flow the airplane. The second instrument approach was made for a landing at the Se5ittle- Tacoma Airport, sometimes referred to as the Bow Lake Airport, which is located 4 miles south of the Seattle radio range station. The airplane was flown inbound on the northwest course of the range. Then, after passing over the range station at 1,500 feet, a heading of 193 degrees toward the airport was flown, and a descent made for landing. The aircraft was first observed at the Scattle-Tacoma Airport when approximately 500 feet above the encroach end of ftimvoy 20, 5,611 feet long, at which tame it was flying at an angle to * the left of that runway. An S" maneuver and rapid descent were made. A right turn was entered and held until "he airplane was again over Runway 20, then it turned loft. When the airplane first jnade contact with the runway ? it was in the left turn, and the left wing was so low that those who observed F the landing thought that it would strike the ground. The first point of touchdown was made 2,748 feet beyond the approach end of the runway. The airplane progressed over the remaining distance of the runway without apparent deceleration. Captain Fams, who had taken over the controls of rhe airplane when it was in the left turn, stated that he allowed the air- plane to slo" down of its own accord to 50 or 60 miles per hour before pplying brakes, pud that- he released the emergency air bottle 1,000 feet from the end of the runway. Before passing ov&r the end of the runway an attempt was made to groundloop the airplane to the lef t by applying power to engine 4, Nevertheless, tnc airplane traveled almost straight- ahead. It went off the end of the runway, crossed 229 feet of wet ground, and then rolled sown a 24-foot embankment. At the bottom of the embankment it struck a ditch which sheared off the left landing gear end left wing. The aircraft continued on to the intersection of the Des Moines Highway and South 188th Street where it collided with ? moving automobile. Spilled gasoline was ignited, and the wreckage was enveloped in flames. The Weather Bureau at the Seattle-Ibcoma Airport made an observation immediately following the crash and reported an L indefinite ceiling, 400-foot overcast, visibility variable one-half to one mile, and light ram and fog. Investigation Narratives of the flight as told oy captain Farms, Copilot Whitting, and_ Mr, Leslie Greening were not entirely in accord. According to Captain Fams and Copilot WnittaiJg, engines 2 and 3 developed roughness wnen the flight had progressed aoout half-way to Seattle. Captain Farris stated irj effect that- esigmes 2 and 3 became increasingly rough m thoir operation during the remaining portion of the trip; and that by the time the instrument -5- approaches were made, first to Boeing Pield and then to the Seattle-Tacoma Airport, engine 3 Bad become so critical m its operation that the propeller normally would have been feathered On the other hand, Mr. Greening stated that he was at no time aware of a rough operatmg condition of any of the engines. Though Mr. Greening was nor a qualified pilot or mechanic, he had flown the route from Anchorage to Seattle many times before and had accumulated considerable passenger time on the flight deck of C-54 type aircraft. He had had little difficulty m observing the rough operation of the engines during the previous flight when they had returned to Annette Island. Copilot Whitting stated that he observed a rough operatXiig condi- tion of the onsrj nes wnen the flight had progressed about half-way to Seattle, but he said that he was not particularly concerned. He stated that at the time of the two instrument approaches he note eed no malfunctioning of "instruments, gauges, or anything else.'1 According to official Canadian Weather Bureau reports. Comox, ?t the tune tnat the flight was overhead, had an mdefim te 500-foot coiling and 10 miles visibility. According to the United States Weather Bureau reports, Seattle at that time had an indefinite 700-foot ceiling, one mile visibility, ana light ram and fog. Everett, Washington, 25 miles north of Seattle, had an indefinite 1,500-foot ceiling, one-half mile visibility, and light rain and fog. Portland, Oregon, the flight's alternate and 135 miles south of Seattle, was reporting a ceiling of 2,900 feet and a visibility of 9 miles. An hour later, when the flight made its first instrument approach to Boeing Field, the ceiling at Boeing had lowered to indefinite 500 feet, and visibility remained at one mile, ^ho Seattle-Tacoma Airport nad a 600-foot ceiling and 1-1/4 miles visibility. Everett had 1,500-foot ceiling, ano. ore mile visibility. Eugene, Oregon, 257 miles south of Seattle, had a 5,000- foot ceiling, and 6 miles visibility, Portland was reporting a 700-foot overcast with 6 miles visibility. All of the above weather information was given to the flight prior to the time that i+ executed its first instru- ment approach. In addition to the above weather information the flight was advised by the Seattle airport traffic controller that a ground control approach (GCA.) could oe made at the Naval Air Station at Sand Point, Washington, which is approximately 13 miles to the north of the Seattle radio rango s'ation and which at that time had a ceiling of 700 feet and visibility of 2-1/2 miles. Minimums at Boeing Field for landing were ceiling 800 feet and visibility 2 miles. Minimums at the Seattle-Tacoma Airport were coiling 500 feet and visibility one mile. Weather conditions as reported for Everett, Scattle-Tacoma, Portland, and Eugene were above landing minimums. At the time of landing the left outboard tire made a mark on the runway 9 105 feet long. This mark started from the point of first touchdown, 2,748 end of the runway. feet from the approach From the end of this mark none of the aircrafts tires left marks for a distance of 60 foot. Thon, for 293 feet there were marks left by both tires on the left mam landing gear, and these wore in turn followed by marks of all four of the main larding gear tires for a distance of 117 feet, after which the right landing gear tires left no marks for 136 feet. Marks from all 4 landing gear tires appeared again 711 feet from the point of initial touchdown, and continued to the end of the runway, A nosewheel tire mark 144 feet long was loft on the runway at a point whom all h of the main landing gear marks first appeared. These marks on the runway were examined shortly after the accident, Ten months 10b^ed)ifrenvlSalt^ia(^eotS^if^ltfaidnPCoM^IW(0)v2(J04rore still --- t clearly visible and these were again examined at which time it was found that the tires had nibbed or scuffed the top particles of sand free from the concrete thereby exposing a whiter surface Both left tires were skidworn from the landing, the outboard one being worn through tine rubber tread and through several layers of fabric. right inboard tire could not be inspected for wear because it was almest entirely consumed by fire, but the right outboard tire was skidworn from the landing similar to the tires on the left landing gear. The left and right landing gear assemblies were removed from the scene of the accident and taken to a hangar where the shuttle valves for the operation of the emergency air brake system were tested, Ihree of the shuttle valves eperated normally. Bae fourth did not operate because it had been damaged by the extreme heat of the fire. Since evidence was subsequently submitted to the effect that foreign matter was in the hydraulic system at the time of the accident, a more detailed examination was later made of the hydraulic and brake systems than was accomplished immediately after the accident. No foreign matter was found in what remained of the hydraulic and brake systems which would have m itself resulted m total failure of the brakes. In addition, hydraulic fluid was taken from above and below the deoooster valves and sent to the National Bureau of Standards for testing. It was found that this fluid contained no foreign matter which would have impaired the functioning of the brake mechanism, Aircraft records for NC 91009 revealed that on October 14, 1947, 6 weeks before the accident, a complete failure of the hydraulic system was experienced due to a loss of hydraulic fluid. As an m flight emergency measure, the system was filled with a mixture of hydraulic fluid, coffee, water, and fire extinguishing chemicals. After landing, the system was flushed and refilled, and the seal changed m the check valve. Tie next day the hydraulic system 5was again flushed out, the hydraulic pressure regulator was ^.changed, and the brakes and both debooster valves were bled. Tie system was flushed a third time November 4, 1947. The emergency air brake valve was checked November 3, 1947. Tiis check consisted of disconnecting the line at the brake side of the emergency air brake valve and discharging the air bottle from the pilots seat and from the copilots seat. The line was then again connected, after which the entire brake system operated normally. Some difficulty was expen- enced with the brakes November 7, 1947, the left brake being reported inopera tive and the right brake weak. The brakes were bled and then recorded in the aircraft log as operating normally Flushing the hydraulic system after introducing other fluids for emergency operation was not in itself sufficient to cleanse all lines and parts Cylinders, valves, and other units snould have been removed and disassembled sufficiently to assure that no foreign matter or deposits had lodged m any line or orifice of the sys tem. Company records pertaining to the aircraft were subjected to a detailed analysis. Apart from the failure to disassemble the hydraulic system after reported difficulties, no specific item of aircraft maintenance was found that could have contributed to the cause of this accident. This failure to disassemble the hydraulic system was subsequently determined not to have * contributed to the cause of the accident Tests were conducted with a C-54 on Hunway 20 of Seattle-Tacoma Airport, April 28, 1948, to observe the stopping distance and braking action of a C-54 under conditions as nearly similar as possible to those which existed at the time of the accident. But, at the time of these tests the amount of rainfall was considerably less, and the runway was accordingly drier. Hie test airplane was loaded to 55,000 pounds, the estimated weight of NG 91009 at the time of landing. The first landing was made at an air speed of 95 miles per hour with flaps fully down. Brakes were applied so that the tires were skidded intermittently. The braking distance, the point of touchdown to the point where brakes were released, was measured by the Board's investigators to be 2,144 feet. Conditions of the second test were similar to Those of the first except that the brakes were applied so that the tires were skidded continuously. Braking distance was measured to be 2,138 feet by the Board's investigators. Tie third test was made by landing bne airplsno at stalling speed, 78 miles per hour, Tho runway at the time of this landing was dry enough so that the tires, when skidded, made the characteristic dry skid squeal. Stopping distance was measured to be 2,104 feet by the Board's investigators. Tests for a landing at an air speed m excess of 95 miles per hour were not made An experienced airline pilot who rode m the cockpit of the aircraft during the test landings stated that he was ..mazed to find that tho wheels of the airplane had skidded during the test landings, and that he did not believe previously that a heavily loaded airplane could skid so far. Since the tests were not made under the same conditions as those that existed at the time of the accident the results were not controlling m determining the cause of the accident. The only signifiesncies cf tee test .eru that a wet runway was more than a dry one, and that brakes coul4 bo or p wet runway without any braking effect being apparent to those m uhc cockpit. Douglas Aircraft operating data for the C-54 shows tha^ xiien the air- plane is loaded with 55,000 pounos ard banned on a hard dry surface runuay at 78 miles per hour, 990 feet of braking on the runway is required for a full stop. If the toucndown were made at 100 rules per hour, 1,950 feet of braking would be required, and if the touchdown, were riade at 110 mles per hour, 2,730 feet of braking, ionId be required. Since me landing of NC 91009 was iade Oxi a wet runway the required braking distance to cone to a full stop would be greater for tic coefficient of friction on a wet con- crete surface is less than it is on a dry concrete surface Analysis , Ceplain Farris left his seat m the According to nis own testimony < cockpit between 1-1/2 and 2 how's after departure from Annette, or when the flight ra.s about half-iiay to Seattle, Tais was the time that he and Copilot llhitting said that roughness developed n engines 2 and. 3, It appears very unusual that the captain of a flight would ride in a passenger cabin and leave his copilot alone or with a man entirely unqualified as a oilot when engine trouble was being experienced. This, coupled with tne fact that Mr, * Greening observed no engine roughness at any tide during the flight, leads to the conclusion that engine roughness, if it existed, was present only in a very minor degree Certainly, it could not have been so critical as to c J require an emergency landing at either Boeing Field or the Seattle-Tacoma Airport if Hr. Greening was never awar of the condition and if Ur, Farris thought his presence in the cockpit unnecessary. Fuel on board, according to Captain Farris1 statement, was sufficient for flight to either Portland or Eugeno, Oregon, where weather conditions were well above minimum. Thus neither engine trouble nor lack of fuel appears to be r substantial factor in the cause of this accident It is also evident tnat the hydraulic and brake systems of NC 91009 were operating at the time of the landing. Hydraulic pressure was observed to be normal at the time of the pre-landing check; the flaps extended to the full dorm position on final approach for landing; and the brakes operated effectively enougn to skidwear the tires and cause the tire manes on the ruiway which have been described above, parts of which were clearly visible 10 months after the accident. Accordingly, the cause of this accident cannot be attributed to a failure of brakes The instrument pproach to the Seattle-Thcoma Airport whs not made m conformity with a standard procedure. The airplane was flown over the 1 range station and then on a heading of 193 degrees toward the airport. Neither Captain Farris nor Copilot "Whitting had previously made an instrument approach to and landing at the Seattle-Ta coma Airport, and they did not make a track, but rather a heading, of 193 degrees from the range station to the field. As a result they were no+ properly aligned for landing on Runway 20 in S" turn and rapid descent were executed to align the flight path with Runway 20 and to lose the excessive altitude. In doing so, almost half of the runway was flown over before the airplane touched the ground Brat the airplane had considerable speed m excess of stalling at the Because violation of certain Civil Air Regulations was indicated, the Administrator of Civil neronauuics addressed a letter to the pilot asking for payment of a civil penalty. Since payment was refused) an action vas filed m the United States District Court m Seattle by the United States Government praying for judgment against the pilot m the sum of $1,000. tmc of initial contact is indicated oy the fact that even though the airpla was banked so steeply that the left wing tin almost touched the ground there was still sufficient directional control. Excessive speed is also indicated I by the fact that after the airplane had skidded 105 feet on the left outboari tire, it became airborne and flew 60 feet before again making contact with on the runway until after 711 feet "had been traversed from the point of imta touchdown. Thus, the airolane was landed not only after half the rumay had been flown over, but also when the air speed was above normal stalling sneed. < Findings On the basis of all available evidence, the Board finds that: 1. The earner, airplane, and crew were properly certificated. 2. No evidence was found of mechanical or structural failure which could have contributed to the cause of the accident. .approximately 1-1/2 hours after departure from Annette Island, H-la ska, Captain Farris left his scat on the flight deck and rode for appron matoly 30 minutes m the passengers' cabin, during which time First Officer Whitting handled the controls from the pilot's seat, and a Leslie Greening, not possessed of any pilot qualifications, occupied the copilot's scab. The flight made an instrument approach to Boeing rield after Boeing Tower informed the flight that the ceiling there was 500 feet and the visi bility was one mile. 5- At the time the flight was over Seattle, weather conditions above minimums existed at Payne *ield, Everett, Washington, 25 miles north of Seattle; at Portland, Oregon, 135 miles south of Seattle; and at Eugene, Oregon, 257 miles south of Seattle. 6. The sccona instrument approach was made at the Seattle-Tacoma Air- pert, nnor to which the tower reported the weather there to be ceiling 600 feet and visibility 1-1/4 miles. Immediately after the accident the Weather Bureau observed the ceiling at the Seattle-Tacoma Airport to bo 400 feet ana the visibility variable one-half to one mile. The flight arrived over the approach end of the intended runway too high and not properly lined up for a normal landing. 8. First touchdown was made at a point 2,748 feet from the approach end of Runway 20, 5,611 feet long, at which time the airplane was m a left bank steep enough to place the left wing tip almost on the ground 9. Tie left outboard main landing gear tire marked the runway for a distance of 105 feet after which the airplane flew 60 feet. Seven hundred and eleven feet of runway wore lreversed from the first point of touchdown before all 4 main landing goal wheels were solidly on th o runway. 10. Tie airplane wen+ off the end of the runway, crossed 229 feet of wet ground, rolled down a 24-foot embankment, then collided with the moving automobile at the intersection of Des Homes and South 188th Street. Probable Cause Tie Board determines that the probable cause of this accident was the landing of the airpiano too far from the approach end of a wet runway and at a speed too great to accomplish a full stop on the runway. BI THE CIVIL AEROIAU 'ICS SOIHIB: /s/ JObETd J, O'CCJtoELu. JR. /s/ 0S~ ALL RYAN /s/ JOSH LEE Zs/ HAROLD A. JOY IS /s/ RUSSELL B. AEARS S U P P L J n E T A L DATA Investigation and Hearing Notification of the accident was telephoned to the Chief of Region VII of the Civil Aeronautics j^oard. An investigation was immediately initiated 1 J. m accordance with the provisions of Section 702 (a)(2) of tne Civil Aero- naitics Act of 1938, as amended A public hearing was held in Seattie, Washington, December 11 and. 12, 1947, and a second hearing was held October 1 and 2, 1949, m Seattle, Washington, because of newly discovered evidence Air Carrier Alaska Airlines was incorporated in tne Territory of Alaska. Its executive offices and mam operating base were at Anchorage, Alaska. Alaska Airlines held a certificate of public convenience and necessity issued by the Civil Aeronautics Board to operate as a scheduled carrier in the Territory of Alaska, It held a letter of registration from the Civil Aeronautics Board and an operating certificate issued by the Administrator of Civil Aeronautics to opeiate as a non-scheduled carrier from Anchorace, Alaska, to Seattl Washington Flight Personnel Captain James age 36, held an airline transport pilot rating. At the time of the accident he hod lodged a total K,f 8,352 flying hours, 738 of whicn were in DC-4 aircraft. His last CAa physical examination pnor to the accident was passed i of the His last.physical examination was aecom Civil Aeronautics Act of 1938 as amended . plished June 16, 1947. Captain John Beck, age 37, possessed a Ai r Carrier valid airline transport rating and had flown 9>000 hours, Including 5 in DC-4 American Airlines, Inc., a Delaware type equipment- He was employed by corporation with headquarters in New American Airlines April 15, 1940- His York, New York, was operating as an air last physical examination was accom- carrier under a certificate of public plished September 24, 1947. convenience and necessity and an air car- The other two crew members were Stew- rler operating certificate, both issued ardesses Marlon Fagre and Barbara Chapman. pursuant to the Civil Aeronautics Act of 1938, as amended. These certificates The Ai rcraft authorized the corporation to fly per- sons, property and mail between various NC---90432, A Douglas DC-4 manufactured points including New York, New York, and May 27, 1944, was owned and operated by Los Angeles, California. American Airlines, Inc. It had been Flight Personnel flown 6,231 hours since new. The four Pratt & Whitney Twin Wasp engines had Captain Charles Robert Sisto, age 86, been flown 1 through 4 respectively--- possessed an airline transport rating and 3316:44, 2543:16, 3148:36, and 3303:56 had flown 10,400 hours. Including 1,600 hours. At the time of departure fro in DC-4 type equipment. He was employed Dallas the total weight of the aircraft by American Airlines March 13, 1939. was less than the certificated gross last physical examination was accom- weight, and the load was distributed plished March 21, 1947, more than six L within approved limits with respect to . months prior to this accident. the center of gravity. -'15747 ' (I) SUPPLEMENTAL DATA Investigation and Hearing , p * The Civil Aeronautics Board received notification of the accident at 0715 October 3, 1946 and immediately initiated an investigation in accordance "ith the provisions of the Civil Aeronautics Act of 1938, , * - * a!^ amended. Air Safety Investigators of ihe Boards Nei York offic J ' t 1 arrived at Harmon Field at 2330 the,same day and were later assisted ; f by o*ther investigators of the Safety Bureau staff. A public hearing - was ordered and held at New York, N. October 11, 1946. 1 * s ir Carrier -' American Overseas Airlines is incorporated under the laws of the. State of Delaware and maintains its headquarters at-Hew York, N. Y. At the time of the accident American: Overseas ,Airlines was operating as .flfl carrier under a certificate of public convenience and necessity an air and an air carrier certificate, both issued pursuarit to the Civil Aeronautics Act of 1938, as amended, These certificates authorizted the < company to fly persons, property and mail between various'points in the United States and the British Isles including New York, N. Y. and Shannon, Ireland Flight Personnel - Captain Yfilliam Rogers Westerfield, age 31, of Nevr York, N was pilot of the aircraft and had been employed by the company since February 19, 1946. He possessed an airline transport pilot rating and at the tune of the accident he had accumulated a total of 3,926 hours flying time of itiich 1, 561 hours had been obtained on DC-4 equipment w 2 scheduled departure the flight crew was briefed at the felted States Arny Air Forces Operations at Harmon Field concerning the weather involved in the proposed flight* At approxinately 0445 the captain requested take-off -clearance -fron the control- tower-operator at -Hamon Field and was in structed to proceed to Runway 30. As the aircraft was being taxied toward the take-off end. of Runway 30, the control tower anenonster indicated the wind from 90 degrees at 9 mph. The control tower operator, therefore vised, the flight that a change in runway would be necessary and cleared the aircraft for take-off on Runway 7 At 0500 the aircraft departed Harnon Field on a magnetic bearing of approximately 70 degrees About one minute after take-off -the control tower operator requested a ceiling check from the flight nnd, m acknowledgment, was advised to wwait\ This was the lest rafio contact With the flight. Personnel on the airport who witnessed the t&ke-off observed that about 3 ninutes and 30 seconds after the ship had left the ground a glow of fire appeared approximately 7 aides from the field almost directly in line with the runway on which Aircraft 904 took off. Several attempts were made to contact the aircraft by radio and, inasmuch as none of these was successful, it was presumed that it had crashed. Search operations were initiated immediately by the United States AAF personnel at Earn on Field. The first search party arrived at the scene of the accident several hours after the accident hid occurred ant1 found that the aircraft had teen demolished as a result of impact and subsequent fire and that all ---* 39 occupants had been killed instantly. N Point of impact o east e A-y Stephen vi Yellow "WSI MO LD & KartBOR o * Scale of miles N I 0 I 2 3 5 CHART -OF The above chart shows the approximate flight path of Aircraft 901i after take-off from Harmon Field, and the point of impact The contours clearly illustrate that a turn may have been safely made following take-off from Runway 7 and that a climb could have been accomplished away from the high terrain north of the field. Investigation The aircraft had crashed against a steep ndge at a point 7.1 miles from tne end of Hwiway 7 at a ng of 76 degrees 45 minutes from the center of tne airbort and at an elevation of 1,160 feet.* Tne elevation of Harmon Field is 22 feet,. An inspection of contour charts of this area indicates that the terrain northeast of Harmon Field rises to an elevation in. excess of 1,500' feet through an aximuth extending from approximately 20 degrees magnetic to 90 degrees magnetic# Directly in line with Kimway ? and approximately 7-1/2 riles from the airport lies a de- pressicn the lowest elevation of which is slightly under 1,000 feet# The terrain toward the southeast is relatively flat* The field is bounded by St. George Bay toward tne south. To *ard the northwest several hills rise to an elevation between 1,000 and 2,000 feet The evidence at the scene of the accident disclosed that impact had been made against the side of a nill, the slone of which was approximately 80 degrees. It was apparent that fire had broken out immediately after imj/act and the aircraft burned severely for approximately 9 hours after the time of the accident destruction resulting from impact and fire wai ------ < so complete taat mstection of rhe wreckage provided little information as X ---1 to the condition of the aircraft immediately nrior t^ irrorct. However, marks* of contact with the hill indicated that the aircraft was apuroxirarely straight and level flight et the nonent of impact end no evidence was observed which indicated structural failuie or malfunctioning prior to irroact --- --- , II i ,1 . . ---' ... -i. V . " I ' |l " " I---.......---* 5.W.H I I I | I | --- . --- * All elevations are given in feet above sea level. No take-off restrictions or any special procedures to be employed after take-off from any runway at Harmon Field had been established. Investigation disclosed, however, that the Air Transport Command of the AAF had restricted the rise of this runway and required its DC-4 operation to take-off over water m all instances in which the wind velocity was less than 10 mph. Testimony of control tower personnel indicated that it "'as a general practice for fli^ste * utilizing this runway to make a right turn shortly after take-off. Maintenance records and pilots' reports indicated that the aircraft was an an airworthy condition at the time of this flight. All previous flight crew reports had been given proper attention and the corrective action in each 'instance had been indicated on the appropriate aircraft form. Testimony of Company maintenance personnel at Hamon Field revealed that the aircraft and powerplants were functioning properly prior to take-off and appeared to be operating normally during take-off At the time of the take-off of Aircraft 904, the weather was being reported as: Ceiling 5,000 feet, overcast; visibility 10 miles; wind northeast 10 mph. Approximately 15 minutes later, the v,md was reported 4 mph bit no changes in other weather elements were observed. Neither the moon nor stars were visible through the overcast, and the unlighted terrain in the vicinity of Hamon Field was therefore not visible either in. Captain William R. ' 'esterfiald had considerable aircraft both vails he was flvin with the Air Transport Command and *-n t;ho proceeding nine months with the company.-' A substantial portion of his fli^i'b expor iencc had been accumulated Over this particular route including several operations into and cut of Harr on Field. Hie other members of the crew were also exoerienced m DC-4 operation involving flight over the North Atlantic route. -y- Jr .............. ........ r - - - --- -- - - - T- - - - ' - " ' - " ~ ** o *4 . Discussion Prior to the investigation of this accident the requirements of the Civil Air Regulations, with respect to air carrier operations, and. the application by the Civil Aeronautics Administration of the transport category rules, had. been regarded as providing adequate coVerage of terrain clearance m the immediate vicinity of the airport during and following take-off* Part 41 of the Civil Air Regulations requires that take-offs A shall be nade only fron such airports, in such directionst and under such & gross weight limitations that, in the event of failure of one engine during the take-off, a vertical clearance of at least 50 feet will be assured in the subsequent flight on the remaining engine or engines Since the application of these limitations is dependent upon peculiarities of terrain which differ for each airport and therefore make impracticable uniform regulatory treatment, the determination of the extent of the area within e applied is left to the discretion of the rfiich those regulations shall Civil Aeronautics Administration * Aeronaut i c s In practice, the Civil Administration has confined its surveys to an ar^a within a radius of approximately 3 miles of the airport. R X- * .<' 1r "approval by the CAa of this operation into Harmon Field was granted V on the basis of the transport category requirements discussed above* The engineering data submitted by the company to the Civil Aeronautics Administration with respect to Hamon Field was reviewed an the course of the investigation of this accident and it was apparent that the high terrain into which Aircraft 904 crashed lay beyond the area normally surveyed for - 6 the vurpose of airport approval. Since an area of three rules radius from the center of the airport provides anplcf roc- for aircraft presently in service to naneuver so as to avoid, obstructions lying beyond tnat distance, this approval appeared to be appropriate Although there exists a saddle or pass in the terrain northeast of Hamon Field directly in line with Runway 7, the horizontal distance across this pass is not sufficient to render practicable the passage of aircraft through it as a norual and safe cl mb procedure, and it is unlikely that the pilot was attempting such a procedure in this instance. Since the hills on both sides of the pass are unlighted and the contour of the terrain is not visible under the conditions of darkness experienced at the tine of this flight, navigation through the pass at night would be very difficult In order to guarantee a nininun terrain clearance, therefore, the existence of this pass oust be disregarded for deterninmg the clinb procedure after take-off. Irrespective of whether this particular flight had been complicated by $ soe jnechanical malfunctioning not apparent,in the investigation, with a notnal rate of climb following take-off from Runwey 7, a sale margin of - -f ' clearance over the terrain northeast of Harn on. Field could not be obtained. Tron the facts disclosed during the investigation it oust be concluded that r take-off fron Bunway 7, under the conditions which existed the morning of October 3, was hazardous unless the flight crews were aware of the high terrain northeast of the airport and so naneuvered as to avoid it .Regardless of the wind, safe take-off procedure when using Runway. 7 requires a turn shortly after take-off and a climb to a safe altitude away from the t ** high terrain. Obtained from RareAviation.com. See our selection. Copyright (c) 2004 7- 7 It is the responsibility of the carrier to supply the pilot wit^ all thenavigational data required to provide a safe operation. The navi gat lon- vs al data earned m the cockoit of tins aircraft "adequately described the i terrain in. the vicinity of Harmon Field, and all the information necessary to permit the pilot to determine a climb procedure which would avoid " obstructions m thi direction of take-off was available to hicu Since the " I? direction of climb follovung take-off, which was 35 degrees to the?left of the proposed route* was maintained toward the high terrain noitheast of Harmon Field, it can be concluded that the captain was not alert to the A - * i procedure necessary for a safe climb from this runway. * * 4 f V It is apparent that modem air carrier operation is burdening the pilot with the necessity for evaluation of an increasing number of details, * Since this problem is particularly critical during the take-off and climb, it appears that sone provisions must be nade to assure the execution of a safe * * ' " 1 climb procedure regardless of the complexity of such other factors as aircraft idstriinentation, weather, navigation, and traffic control * In this respect -A- * A it appears that the burden upon the pilot nay, to a' large measure, be " relieved, in operations of this nature by clearly defining the procedures required^for climb after take-off at night or un ger instrument ponditidns. uuch procedures have bee~i established by the air carrier since the -date of <;h the accident, however, none were in existence at the, tine of this flight. -s . -< * While the Civil Air Herniations are not intended tq regulate all details of c air transportation end, therefore, .have not specifically required thrt climb s- procedures-be established at such airports as Karhon. Field, sone regulatory direction may be required -< V is. Because the necessity in instances SUb; i A, sf' C A for clijnb procedures exists at several domestic airports as well as at fields c D.. , D Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviaTion.com r j u \ / - employed m international operation, the Boaru has circulated proposed regulations which are designed to indicate specifically tne responsibility of all U. S. air carriers m this regard. Those regulations would require the earner to define cleaily the procedures for climb from each airport in the vicinity of which terrain or other obstructions present a hazard to flights at night or under instrument conditions. Furthermore, the Board is reviewing the subject of airport approval for scheduled aif earner operations with a view toward revision of the CxVil air regulations in order to assure a complete understanding throughout rhe industry of the nature and extent of airport surveys and the areas to which taxe-off limitations apply. Findings On the basis of all available evidence, the Board finds that: * 1, The aircraft, crew, and company were properly certificated, , iT The aircraft was loaded within approved li^ats with respect to both center of gravity and its maximum, gross weight - 3* The pilot was cleared by the control to1, er operator at Harmon Field,'Stephenville, Newfoundland, to use Runway 30 for take-off, f ' 1 4* wile taxiing into position, the pilot was advised by the tower -7T & 1 to change to Runway 7. * 5. Jiith Shannon, Ireland, as its destination, the aircraft took off Is from Runway 7 at Hamon Field at 0500. 6. Two minutes and 30 seconds after taking off on Runway 7 at Harmon v, X Si" Field, the aircraft crashed against a ridge 7 miles northeast of the airport at an elevation of 1,160 feet Establishment of Take-off and Climb Procedures for Night or Instrdraent Flight RareAviation.com. See our selection. Copyright (c) 2004 r.-. * l 9 - 7. No restrictions had been placed on the use of runways for take-off V y and no special procedures had been established for climbing to cruising altitude following take-off from Harmon field 8. The navigational data carried in the cockpit of the aircraft were sufficiently complete and accurate to have enabled the pilot to deterMne a satisfactory climb procedure following take-off from Runway 7 Probable Cause On the basis of the foregoing, the Board determines that the probable cause of this accident was the action of the pilot in maintaining the direction of take-off toward higher terrain over which adequate clearance could not be gained. BY THE CIVIL AERONAUTICS BOARD? /s/ J, M. LANDIS AZ - Qg.AU). RYANL_ /s/ . JOSH ISE. CLARENCES YOUNG Harllee Branch, Member of the Bo?rd> did not take part in the decision SUPPLEMENTAL DATA Investigation and. Hearing The Civil Aeronautics Board received notification of the accident aft 0715 October 3, 1946 and immediately initiated an investigation in accordance 'ath the provisions of tne Civil Aeronautics Act of 1938., a's amended. Air Safetyinvestigators of tne Board's Ne. York office arrived at Harmon Field at 2330 tee.same day and were later assisted 3 * f < * by other investigators of the Safety Bissau staff. A pu,blip hearing nas ordered and held at New York, !J. Y*, October 11, 1946, * k, r i Air Carrier American Overseas Airlines is incorporated under the laws of tea State of Delaware and maintains its headquarters ate Heir York, N. Y. At the time of the accident American* Overseas .Airlines was operating as an air carrier under a certificate of public convenience and necessity and an air carrier certificate, bote issued pursuant to the Civil J Aeronautics Act of-1938, as amended Ihese certificates authorized the A V* company to fly persons, property and mail between variouspoints m tne United States and the British Isles including New York, N. Y* and Shannon. Ireland Hight Personnel 4 Captain 1',illiam Aogers Westerfield, age 31, of New York, M. Y pilot of the aircraft and had been employed by the company since February 19, 1946. He possessed an airline transport pilot rating and at the ne of the accident he had accumulated a total of 3,926 hours* flying tune of -hich 1,561 hours had been obtained on DC-4 equipment Bobert Becknan Lehr, of Middle Village, New York, was copilot and had een employed by the conoany since July 16, 1945. He possessed a connercial pilot certificate and. an instrument rating and until the date of the accident he had accumulated a total of l#707 hours, of which. 805 hours had been obtained in DC-4 equipment, John T. Tierney, Jr senior navigator; Jerome Lewis, junior navigator; Mark Spelar, flight engineer; Janes N. Berry, radio officer; Herbert D* Ewing, purser, and Peggy Anu Burleigh, flight stewardess, comprised the remainder of the crew Both pilots Were properly certificated for the flight and the captain had qualified over the route Aircraft I *.1 .1 The Douglas DC-4, NC-90904, was manufactured in March 1945 and had. accumulated a total of 3,731 hours, It was equippe with four Pratt and. Whitney B-2000-9 engines on which were installed Hamilton Standard hydro * matte propellers, The total tines logged for the engines were* 1,857 hours, 1,561 hours, 1,394 hours and 1,509 hours for the Nos, 1, 2. 3 and 4 engines, resnectively Since the last major overhaul the sngines had logged the following tines. 401 hours 754 hours, 33 hours and 833 hours. At tne time of departure fron Stephenville the total weight of the aircraft was 200 pounds less than the approved maximun take-off weight of 71, 800 pounds and the load was distributed with respect to the center of gravity within approved limits - 11 from RareAviation.com. See our selection. Copyright (c) 2004 ACCIDENT INVESTIGATION REPORT Adopted: September 23? 1952 Released: September 29, 1952 BRANIFF AIRWAYS, INC., NEAR HUGOTON, KANSAS, MARCH 26, 1952 The Accident A Douglas DC-b aircraft, N 651U3, owned and operated by Braniff Airways Inc., made an emergency landing because of an engine fire in flight on HAP Airport near Hugoton, Kansas, at approximately 1730,March 26, 1952. tie b5 passengers ano crew of four, one passenger received a minor injury. The aircraft was substantially damaged by fire. History of the Flight Braniff Airways1 Flight 65 departed Denver, Colorado, at 1535 on March 26, 1952, for Dallas, Texas, with intermediate stops scheduled at Colorado Springs, Colorado, and Oklanoma City, Oklahoma, The crew consisted of Captain J. W. Stanford, First Officer J. P. Beakley, and Hostesses Dorothy Currey and Betty Murphy. The flight arrived at Colorado Springs after a routine trip and departed there at 1620. On departure it was cleared IFR (Instrument Flight Rules) direct to Lajunta, Colorado, and then by Red Airway 35 to Garden City, Kansas, and Red Airway 59 to Oklahoma City; to cruise at 8,000 feet to la.Junta, and to descend and maintain 7,000 feet from Lajunta to Oklahoma City. According to company records, the gross weight of the air- craft was within approved limits and tne load was properly distributed. At 1653 the flight reported over Lajunta at 8,000 feet, descending to 7,000. Four minutes later, at 1657, the flight canceled its IFR flight plan and advised that it was proceeding VFR (Visual Flight Rules) direct to Oklahoma City via Liberal, Kansas. When m the vicinity of Hugoton, Kansas, at approximately 6,000 feet MSL, (3000 feet above the ground), one of the hostesses advised the crew that the right wing was on fire. This was the first indication the crew had that anything was wrong, as the fire-warning signal devices had not functioned and all engines appeared to be operating in a normal manner. The captain immediately looked through the small window in the forward cargo loading door on the right and saw a brilliant red reflection on the inboard surface of the No. b engine nacelle. Because of the brilliance of the reflection and the fact that it covered the entire visible portion of this nacelle, he believed the fire was of considerable proportion He immediately asked the copilot where the fire was and was advised that he thought it was No. 3. 1/ All times referred to herein are Central Standard and based on the 21i-hour clojktajnec| from RareAviation.com. See our selection. Copyright (c) 2004 The captain then decided to land as quickly as possible on a small airport near Hugoton, which he had seen only a few seconds before the hostess came to the cockpit. Accordingly, the hostess was told to ad- vise the passengers that an emergency landing was to be made, and the "Fasten seat belt" and "No smoking" signs were turned on. The captain then disengaged the autopilot, closed the throttle of the No. 3 engine, put the mixture control at idle cutoff, closed the fuel selector valve, and set the propeller control at the full high pitch position. Following this, he dived the aircraft m an attempt to extinguish the fire and to lose altitude. At this time the copilot asked the captain if he wanted the No. 3 engine's propeller feathered, and the captain said, "No." When an air speed of approximately 230 miles per hour was i^ached, power was reduced on the remaining three engines. During the dive the aircraft was heading in a southeasterly direction, and after a short time the dive was decreased and a steep left turn was made to a westerly heading. When the air speed decreased to approximately 200 miles per hour, the captain pulled the No. 3 fire extinguisher selector valve control handle (this also operates the fire wall shutoff valves), and then pulled the discharge handle of the left 00^ bottle. When this bottle was discharged, the reflection on the No. 4 engine nacelle was observed to diminish appreciably. The captain said that at this time he thought he asked the copilot to discharge the right CO 2 bottle; however, this bottle was not discharged. The landing gear was lowered, and power was resumed on the three remaining engines, About this time the fire warning light in the cockpit came on, and the bell rang These warning signals continued to operate intermittently, As soon as the gear was down, the descent was steepened and a series of steep slipping "S" turns were made toward the north while approaching the airport. At an altitude of approximately 200 to 300 feet above the ground, a pronounced buffeting (similar to that which accompanies a near stalling attitude) was experienced. This buffeting was so pronounced it was difficult to control the aircraft; however, it soon stopped and normal control was again resumed. When the buffeting occurred, the indicated air speed was approximately l$0 mph. It is believed that the No. 3 engine fell from the aircraft at this time. The captain next called for full flaps. Although the copilot immediately executed uhis command, no apparent effect of the flaps being lowered was noticed by the crew, and a few seconds later, the aircraft touched down m the middle of the airport, The captain applied brake pressure immediately, but the air- craft did not decelerate . Approaching the north boundary of the field, the captain tried to turn left to avoid crossing a road which was adjacent to the airport, but the nose steering wheel was inoperative. Left rudder was immediately applied; however, the aircraft responded so quickly to this action that right rudder had to be applied at once to keep the air- craft from groundlooping After the aircraft was dgain rolling straight, the captain pulled back on the wheel, causing the nose wheel to lift from the ground, and the aircraft rolled beyond the airport boundary across a highway, through two fences and a ditch, and came to rest m a wheat field All of the occupants were evacuated m an orderly manner some through the forward compartment and mam cabin doors by using descent ropes and a few by means of an emergency exit located on the left side of tne aircraft. c d i 1 .Obtained from RareAviation.com. See our selection. Copyright (c) 2004 FromP1lotManuals.com/KareAv1ax1on.com rs 0 \ / Investigation Weather was not a factor m this accident, At the time of tne accident the ceiling was 12,000 feet, visibility 15 miles, and wind from the north approximately 10 miles per hour. HAP Airport is located miles southwest of Hugoton at an elevation of 3,107 feet MSI. It has several turf runways, the longest of which is 2,600 feet. Passengers on board the aircraft said that when they first observed the fire, flames were extending slightly beyond the trailing edge of the wing and as the fire increased in intensity, the flames lengthened. One passenger, who was also a pilot, said that the flames were light yellow or amber and that they appeared to be coming from beneath the wing behind the No. 3 engine nacelle. The fire was first observed by ground witnesses when the aircraft was approximately 11^ miles from HAP Airport on a bearing of degrees true. Other witnesses said that when the aircraft was approaching the air- port at an altitude estimated to be about 300 feet above the ground, they saw the burning No. 3 engine fall from the aircraft. This engine was found approximately one mile southeast of the airport. Related parts to this engine, its nacelle, and a portion of the skin on the underside of the right flap were also found back along the flight path for a distance of 2i miles.2 Investigation revealed that the aircraft was not badly damaged during the landing. According to ground witnesses, the fire was confined to the No. 3 engine nacelle and the adjacent wing area when the aircraft stopped and did not appear to be burning intensely. It gained impetus, however, and destroyed a large portion of the aircraft. The fuselage was destroyed by fire from Station 61i (located immediately forward of the pilot's cockpit) rearward to the empennage. Examination of the burned cockpit showed the landing gear and flap controls m the down position and the carburetor mixture controls of all engines at idle cutoff. The intense fire m this area made further readings impossible. The undersurface of the left wing showed evidence of having been subjected to considerable heat; the wing structure had buckled slightly from the forward junction of the wing with the fuselage diagonally out- board and rearward to the trailing edge of the No. 2 engine nacelle. The upper surface of all other portions of the wing was undamaged. The left aileron and controls were not damaged. The flap and flap controls were not seriously damaged by the fire and could be manually operated. The right wing was not damaged outboard of the No. U engine nacelle; however, between the nacelle and the fuselage, this wing was badly damaged by fire after landing. The right aileron was intact except for a section of its inside covering which was burned off. The right flap was badly burned 2/ See Appendix A. Obtained from RareAviation.com. See our selection. Copyright (c) 2004 Both fuel tanks m the left wing were undamaged. The inboard fuel tank in. the right wing was completely burned out, the outboard fuel tank had holes in its stricture, apparently caused by heat. Considerable fuel remained m the outer end of this tank after the fire subsided. Nos. 1 and 2 engine nacelles were undamaged. The No. 3 engine nacelle was missing forward of the front spar. The lower portion of the No, li engine nacelle was dented by contact with the ground when the right wing buckled sometime after the aircraft had stopped. This nacelle was also slightly damaged by fire. The landing gear was in the down position and locked. The nose gear was not damaged. The air bottle which actuates the emergency brakes and is located m the nose-wheel well was discharged, but it was determined from the damaged condition of its valve that heat had caused the discharge of this bottle. The captain said that the emergency brakes were not used during tne landing roll. The mam landing gear was severely damaged and the wheels and tires were consumed by fire. Most parts of the No. 3 engine assembly and its nacelle were recovered, These parts, together with this engine, were sent to Dallas, Texas, for further examination and analysis. At Dallas a reconstruction was made of the No. 3 engine nacelle, using all parts which were recovered and identifiable, m an effort to determine the fire pattern. A study of this assembly revealed no evidence of fire m Zone 1. There was considerable evidence of fire m Zone 2, with the intense fire area being confined to the lower right rear portion of this zone. Evidence of fire was noticeable to a lesser degree m the lower left rear portion of this zone and also forward and immediately below the rear accessory case. The vacuum pump housing was broken above the inlet boss, and the lower portion of the housing, including the steel sleeve, rotor and vanes, was missing. The section of the vacuum pump housing which includes the fusible plug was attached to the engine rear case pad; the fusible alloy m the plug was missing. The inlet line to the vacuum pump was torn and frayed near one end. Examination of the remaining three engines showed that the vacuum pump inlet line was installed so that it passed extremely close to the air exit opening of the generator housing. The vacuum pump oil separator, which is located on the upper right forward side of the fire wall, was missing, and all vacuum pump lines were badly burned. The generator, normally mounted on the rear of the engine directly above the vacuum pump, was missing The generator housing was recovered, and its lower right side showed considerable evidence of fire, Several turns of the blast tube former wire were wrapped around the housing The terminal block and brush assembly were missing. The armature, minus its pencil drive shaft, was recovered. The front and rear inner ball bearing races of the armature were attached to the shaft, and these had been subjected to intense heat. The front and rear outer bearing races were missing. Marks on the armature throughout 180 degrees of its circumfer- ence indicated that it had whipped and rubbed against the pole shoes. The motor section of the starter was missing, the gear section remained attached to the engine* The external right side of the starter case , which is mounted immediately above the generator, had been subjected to heat All of Zone 3 was badly burned* The rear portion of the oil tank was missing. The electrical junction box located on the rear side of the fire wall was destroyed* Although there was considerable evidence of fire throughout this entire area, the landing gear tires were not badly damaged during flighto This was evidenced by tire markings on the ground made during the landing roll. The No. 3 engine was subsequently disassembled and examined, The drive shafts of the vacuum, fuel, and hydraulic pumps were discolored by heat. The rear portion of the generator drive shaft was scored, and it showed evidence of having rotated unevenly before the generator broke from its mount, the staking pin was loose* Although the engine was severely damaged by impact with the ground, no evidence was found to indicate that it failed in flight The fire-detection system consisted of three circuits: the detector circuit, the fire warning circuit, and the test circuit* Two detector circuits were employed, one protecting Zone 1 and one protecting Zones 2 and 3- Twenty-six detector units were used in the protection of each engine. tohen the engine fell from the aircraft, the circuits were torn and so damaged by fire that it was impossible to determine why the system failed to operate. The captain stated that the fire warning signals operated a short time before the aircraft landed and that these signals continued to operate intermittently even during the landing roll. A polarity check of the fire-detection system of No* 1 engine revealed that the two leads which formed the ends of a portion of the Zone 2 and 3 detector current and which were connected to the fire wall connector plug, had been connected in reverse at tne first detector box* This resulted in reverse polarity being produced at the fire wall connector plug pins* With these wires reversed, the test circuit light would function normally if checked by the crew, but the system should not operate properly m the event of a fire* Portions of the No. 3 engine fire-detection circuit wiring were sent to Washington, D. C, for additional study. Nothing was found to indicate that this engines fire-detection system was wired incorrectly, nor was it learned why this system failed to function properly. The companys Operations Manual, under Emergency Procedures, specifies the following: WING FIRE* If A wing fire exists, shut off fuel, tank selector, cross-feed valves and booster pumps and LAND AS QUICKLY AS POSSIBLE. Under Engine Fires, the manual lists the following procedure to be followed: Gear up; flaps, as required; throttle, closed; propeller control, lowest RPM, mixture, idle cutoff; feather, check button for snap out; increased power, as required; fire wall shutoff, pull; fuel selector and. cross-feed, off; vacuum, check; booster purr?), off, generator, off; cowl flaps and mixtures, as required; ignition, off; fire extinguisher, as needed.11 The pilot's check list does not include any emergency- procedures. The captain said that when he was informed the wing was on fire, and saw the brilliant reflection on the No. Ij. nacelle, he did not definitely know whether it was the wing or the No. 3 engine which was burning. He therefore decided to land as quickly as possible and this landing was accomplished m less than four minutes. A review of the records of Captain Stanford's DC-Li flight training, together with his route and instrument checks, indicated his flying ability to be above average. These records also showed that he had satisfactorily completed DC-b emergency procedure and evacuation training. Analysis A study of past in-flight engine fires has shown that the majority of fires originating in Zone 3 have not progressed forward into Zone 2. In this instance it is possible that the flexible bus, which extends from the junction box on the rear of the fire wall in Zone 3, through the fire wall along the inside of the leading edge of the wing, could have short-circuited at or near the junction box and created a fire. This would have occurred if the insulated copper cable of the bus had chafed against the inside wall of its aluminum conduit, which is grounded to the aircraft frame. However, the cable did not reveal any evidence of electrical arcing despite the fact that the conduit and cable insulation were destroyed. It is believed more likely that the fire originated m Zone 2. This could have occurred in several ways. If the flexible oil pressure gauge line rubbed against the positive terminal of the generator and wore a hole through the cable to the metal braid, arcing would have resulted which would eventually ignite the escaping oil. A nacelle fire from such a cause had occurred only a few weeks prior to this accident, on this same aircraft. However, the company was alerted to such a possibility, and had taken the necessary corrective action. Another possibility is that the generator failed mechanically, causing intense frictional heat to be transferred to the vacuum pump inlet line which was installed m close proximity to the generator. The temperature of the air which flows through this line would then be increased to such an extent by the action of the punp that it would melt the fusible plug which is designed as a safety factor to melt at a temperature lower than that of combustion. Oil vapor would then be released into the nacelle, and tms vapor could be ignited by sparks from the failing generator. Since the alloy of the fusible plug did melt, this possibility cannot be discounted. This could also have occurred if there had been a restriction in the pressure discharge line of the vacuum pump. Captain Stanford stated that when the emergency occurred he did not know whether the right wing or the No. 3 engine was on fire and that his prime consideration was the saving of life by landing as quickly as possible. Bile the emergency procedures set forth m the companys Operations Manual were not followed m their entirety, m this instance it does not appear that the failure to do so resulted in any way in making the situation worse. In fact, had the oil line to the feathering mechanism been weakened or burned through by the fire, an attempt to feather the No. 3 propeller would have sprayed hot oil throughout Zone 2 of the nacelle, greatly intensifying th fire. The captain also said that the emergency air brakes were not used during tne landing roll because m his judgment the application of these brakes would have forced the nose wheel immediately to the ground and with the high speed of the aircraft at that time serious damage might have resulted by the gear striking an obstruction. Since the aircraft did roll across a highway and through two fences and a ditch before stopping, it appears that the captain exercised good judgment m not using these brakes. bindings On the basis of all available evidence, the Board finds that The carrier, the crew, and the aircraft were properly certificated 2. Weather was not a factor in this acciden 3. A fire m the No. 3 engine nacelle, which necessitated an immediate landing, was observed when the aircraft was in the vicinity of Hugoton, Kansas 4. When the aircraft was approximately 300 feet above the ground the Uo. 3 engine fell from the aircraft. 5. The fire-detection system did not function properly 6. A safe landing was made on a small airport which was unsuitable for DC-4 aircraft. probable Cause The Board determines that the probable cause of this accident was an uncontrollable engine fire of unknown origin which necessitated an ironediafr landing. BY THE CIVIL AERONAUTICS OARD: DONALD W. NYROP /s/ OSWALD RYAN /s/ JOSH LEE /s/ JOSEPH P. ADAMS /s/ CHAN GURNEY Obtained from RareAviation.com. See our selection? Copyright (c) 2004 ' SUPPLEMENTAL DATA Investigation, and Hearing The Civil Aeronautics Board received notification at 2000, March 26, 1952, from the Kansas City office of the Civil Aeronautics Administration, that an accident had occurred near Hugoton, Kansas, at approximately 1725, involving an aircraft owned by Braniff Airways, Inc. An investigation was immediately initiated in accordance with tne provisions of Section 702 (a)(2) of the Civil Aeronautics Act of 1938, as amended. A public hearing in connection with this accident was held in Dallas, Texas, on April 24 and 25, 1952. Air Carrier Braniff Airways, Inc., is an Oklahoma corporation, with its principal offices in Dallas, Texas. The company operates as an air carrier under a certificate of public convenience and necessity, and an air carrier operating certificate issued pursuant to the Civil Aeronautics Act of 1938, as amended. These certificates authorize the carrier to engage in air transportation between various points m the United States, South America, and Mexico. Flight Personnel Captain J . W. Stanford, age 40, was employed by Braniff Airways, Inc., on February 16 , 1941. He held a valid airman certificate with an air trans- port rating. Captain Stanford had a total of 10,271 flying hours, of which 3o9 were in DC-4 equipment. His last instrument and route checks were accomplished on February 8, 1952. He received his last CAA physical exannna tion on September 26, 1951. First Officer J. P. Beakley, age 29, was employed by the company on July 31, 1950* * He held a valid airman certificate with an airline transport rating* He had a total of 2,797 flying hours, of which 95 were m DC-4 equipment. His last instrument and route checks were accomplished February 26; 1952, and his last CAA physical examination on January 11, 1952. Hostess Dorothy Currey was employed by the company on November 20, 1950. Hostess Betty Murphy was employed by the company m April 1951 The Aircraft N 65143s a Douglas Model C-54A, was owned and operated by Braniff Airways, and was currently certificated by the Civil Aeronautics Administra- tion. It had a total of 11,679 hours, and was equipped with Pratt & Whitney R-2000 engines and Hamilton Standard 23E50 propellers. The engines had been operated since overhaul as follows No. 1, 722 hrs* 52 min.; No. 2, 6 hrs. 2 mm.; No* 3, 378 hrs. 29 min.; No. 4, 627 hrs. 28 min. 4- --- From PROBABLE FLIGHT PATH AND LOCATION OF FALLEN PARTS BRANIFF AIRWAYS ACCIDENT HUGOTON. KANSAS --- MARCH 26. <9 52 I "at^CW 0# 4^*c*4i- WR a *cY* .C*AFy fcFr?S HUGOTON * t i OTO* > e * T 4 i sow. > _ fc-w b. Si i i I WWg J .Jks4C--MQ xca S 4>5? >- i* WgTJt i*u. --- but jc-;xss>:^ C4>.rs>3* > *a*3A>"' C Y XF^ > CAS-'A;*? XS C* ?-*<. 3.' I -K i. & t . I ? rwr-w-x -*-w*-r W* * ---' ** * ^/-r*ArVA'W.'^.^ -v -*-* F---r---i ; ^..... bl t ,- .x^>y Ht W-l fr Obtained from RareAviation.com. See our selection. Copyright (c) 2004 SA- 245 File No. 1-0098 CIVIL AERONAUTICS ACCIDENT INVESTIGATION REPORT Adopted: October 1, 1952 Released: October 1, 1952 CALIFORNIA EASTERN AIRWAYS, INC. AND OVERSEAS NATIONAL AIRWAYS, AIR COLLISION - NEAR OAKLAND MUNICIPAL AIRPORT, OAKLAND, CALIFORNIA, NOVEMBER 17, 1951 The Accident California Eastern Airways training flight, a DC-4, N 4002B, and Overseas National Airways training flight, a DC-4, N 79992, collided at an altitude of about 3000 feet MSL at approximately 1013,1/ November 17, 1951* Both aircraft were making simulated instrument approaches to the Oakland low frequency radio range. The three captains in the Overseas National DC-4 were killed, and the aircraft was destroyed by impact and fire. The two captains and one mechanic in the California Eastern DC-4 were not injured, but the aircraft received sub- stantial damage. History of the Flights Overseas Nationals DC-4?/ took off from the Oakland Airport at 0820. Captain Marion Harvey Click, company check pilot, was in command and aboard were Captains Hammond Garrard and Warren Oecil Gessner who were to receive their six months DC-4 instrument competency checks. There were no other persons aboard. The aircraft had been refueled with 1,229 gallons of gasoline and 11 gallons of oil; the total load was within the certificated gross weight and was properly distributed* At 0923, this flight received a clearance from the Oakland tower to make a practice range approach and to remain above 1,500 feet on the final approach to the airport. At 0935, the California Eastern DC-4?/ took off from the Oakland Airport for the purpose of a six-month instrument competency check. Captain Ralph A. Shope, company chief pilot, was in command and occupied the right seat. Captain Winfield B. Kinner, receiving the check, was in the left seat. Louis Goldberg, an upholsterer and company mechanic, occupied a cabin seat and was on board only to sew some arm rests. The aircraft had been refueled with 1600 gallons of gasoline, and the total load was within the certificated gross weight and was properly distributed. According to accepted practice, both flights conducted their training checks in the "Bay area, with all maneuvers above 3,000 feet. Both aircraft were equipped with hoods, installed on the left side of each cockpit to All times referred to herein are Pacific Standard and based on the 24-hour clock. 2/ Henceforth referred to as "Overseas, Z/ Henceforth referred to as "California. c D, , D A Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com r j o \ / prevent the pilots being checked from seeing outside The check pilots in th right seats, also perform the duties A f safety pilots, maintaining watch for other aircraft. There was also a third pilot on board Overseas who acted as an observer. Shortly before 1013, the approximate time of the accident, both aircraft approached the Oakland low frequency radio range station, which is 0.2 mile northeast from the approach end of Runway 15 of the Oakland Airport Overseas was on a magnetic heading of approximately 124 degrees inbound on the NW leg of the range; and California was homing on the range on a heading of 75 degrees M.jy Both aircraft were at an altitude of 3,000 feet. Weather conditions were good in the San Francisco Bay area at the time. The D. S. Weather Bureau reported at 1016 (three minutes after the accident); ceiling 25,000 feet, thin broken clouds, visibility seven miles, wind south four mph at Oakland. The suns bearing at 1015 was 153 degrees true, and its altitude above the horizon was 28 degrees and 27 minutes. During a short period prior to 1013, both aircraft were observed to converge without any apparent change in direction or altitude, Neither attempted to avoid collision but remained in straight and level flight, and collided approximately over the range station at an altitude of about 3,000 feet. California was at a slightly lower altitude than Overseas, and contact was made between the leading edge of the vertical stabilizer of California and the right side of the fuselage of Overseas just forward of the horizontal stabilizer. Shortly after the collision, Overseas crashed out of control on Doolittle Drive, the highway paralleling the north side of Oakland Airport. Its three pilots were killed at the time of impact with the ground. A number of persons driving on the highway close to the impact site received burns of varying degrees, and several automobiles were destroyed by fire. The top portions of the vertical stabilizer and rudder of California were torn off in the collision The aircraft was still controllable at an air speed of 160 miles an hour Immediately following the collision, Captain Shope had Captain Firmer remove the hood, As California was then south of the Oakland Airport at 2,500 feet Captain Shope requested per- mission to land on Runway 9R, the longest runway, and to have emergency equipment stand by. However, since all fire equipment was then at the crash scene of Overseas, the flight was directed to the San Francisco Air port, 12 miles away, where an emergency landing was made at 1021. Investigation Overseas struck the ground at an angle slightly beyond vertical. It did not move appreciably after impact and burst into flames immediately. Local fire fighting equipment extinguished the fire after considerable fire damage had occurred. The bodies of the three pilots were extricated, and the wreckage was removed from the highway to restore traffic. It was determined that Captain Garrard was in the left seat, and Captain Click m the right seat. Captain Gessners position could not be determined. As a result of ground impact, all four engines broke from the structure, and all four propellers and nose sections broke free of their respective engines. Both wings and the fore part of the fuselage had been exposed to considerable heat, and the rear of the fuselage was flattened. The main part of the aircraft was 1,425 feet southeast of the center of the Oakland Range Station. The entire empennage had been severed at the time of collision and fell free of the aircraft, landing 1,350 feet southeast of the range station. Inspection of Overseas* empennage, which had separated from the fuselage at a point just forward of the horizontal stabilizer*s leading edge disclosed aluminum paint marks running m the horizontal direction on the rubber de-icer boot of the fight horizontal stabilizer, starting about eleven feet in from the tip and continuing inboard to where the de-icer boot was torn free near the inboard end. The inboard portion of the leading edge of the right horizontal stabilizer was flattened. The fuselage had been struck on the right side about on a line with the leading edge of the horizontal stabilizer Blue paint marks were found on the fuselage m this area. Further examination of Overseas* rear fuselage disclosed a twenty foot length of antenna wire lodged in a tear in the side-skin at station No 920 This wire was of a stranded type and was positively identified as having come from the top antenna of California. All control cables which passed through the damaged rear fuselage area were severed by impact forces or by subsequent tearing forces damaged as the tail unit left the aircraft.^/ Two pieces of the top portion of the vertical fin from California were found 1,300 feet east from the center of the Oakland Range Station. An in- spection of California at the San Francisco Airport reveialed that the vertical tail surface was sheared off irregularly approximately 20 inches above the center rudder hinge. The dorsal fin portion was painted blue, accounting for the blue marks on Overseas. An inspection of the maintenance records of both aircraft indicated that they were in an airworthy condition at the time of take-off, and there was no indication from either flight of any malfunction prior to the collision. As stated, both carriers were conducting six-month pilot DC-4 checks, The first chase of the work consisted of practice turns, 'Stalls and other mane uve r s It was customary for such training flights to use the area in the south and southeast quadrants of the Oakland range Also a portion of the six-month check consisted of orientation, beam bracketing cone ldentifica- tion, and approach procedures Dunng these checks the hood is up to require the pilot in the left seat to fly solely by instruments The hoods installed in both aircraft were of fabric. The one in Overseas obscured the left windshield, except for its top two inches (approximately), and the left side glass except for its top six or eight inches. Californias installation covered the left windshield, except for about four inches from the center, and all of the left side glass. The safety pilot of California could see to his right, ahead, and to the left of ahead by about 45 degrees. 5/ See Attachment B, a photograph of two model DC-4s placed in the approximate relative positions as the two aircraft at time of collision. However, reference to Attachment A shows that Overseas, during the final stages of flight, was at a relative bearing of 53 degrees to the left of California, preventing its safety pilot from seeing Overseas. Overseas was making a standard range approach to the Oakland station inbound on the northwest leg (124 degrees) at an air speed of approximately 140 mph, and maintaining 3,000 feet, the initial aonroach altitude, all m accord with company procedure, The company also required an "in range check list, which was in effect for training flights This check list is read by the check pilot and the response is made by the pilot being checked. This list is: Altimeter "SET." 2 Seat belt - no smoking sign "ON." 3 Wing and prop de-icers OFF tl Cabin and cockpit heaters and galley switches "OFFr" (Not applicable.) 5. Driftmeter "CAGED and "OFF. (Not applicable.) 6. Trailing antennae "IN." (None on this aircraft.) Main Tanks "ON. "COLD." Carburetor air kJ ft tt 9. Cross feed "OFF. (None installed on N 4002B.)^/ 10. Blowers "LOW." 11. Hydraulic by-pass "DOWN. ItiwimT tt pre s sure T*UP e * 12. Hydraulic hand pump valve . "CLOSED (forward). 13. Automatic pilot servo ! "OFF. 14. Parking brake "OFF." 15. Mixtures "RICH." 16. Check magnetos. 17. Gear handle "IIP," flaps as required Captain Byron Sherrill, Overseas Chief Pilot, testified that this check is completed one or two minutes prior to arrival over th w range station on the initial approach. H further stated it required about one minute to complete this check. According to approved company procedure, at least three pilots are scheduled for training flights so that one can act as an observer. Normally, this observer stands on the navigators stool looking from the astrodome, particularly during turns and other maneuvers. He also is required at times to look from cabin windows on the left side for other aircraft. Company practice requires the flight to contact the tower, even under VFR conditions, one to two minutes prior to reaching the range station, for permission to make a simulated low approach to the airport. The Oakland Tower records revealed that Overseas was cleared to make an approach at 0923, fifty minutes prior to the accident, but no request from Overseas was received by the tower immediately prior to 1013. The captain of California testified that he was just about to contact the tower m accord with his companys practice when collision occurred. However, under existing Civil Air Regulations neither flight was required to contact the tower under VFR conditions. Zj By this is meant that the "high blower" was deactivated leaving the engine continually in "low blower." California required an ADF approach during the check flight, and at 0950 Captain Shope requested Captain Kirtner to do a "time and distance problem from the Oakland Radio Range Station. After orienting himself m relation to the range station and estimating the tune therefrom as four minutes 9 Captain Kinner took up a heading of 75 degrees holding an altitude of 3,000 feet, air speed 170 mph. As the flight crossed the range station at 1013, a rather abrupt jar was felt and California was swung about 30 degrees to its right. From his right, Captain Shope observed the other DC-4 descending at a sharp angle; he had not seen it previously. Captain Shope testified that a flight plan had been made out on the morning of November 17, 1951, which listed the names of three other captains who required flight checks; however, since these pilots were not present at the designated time, the flight departed without them. Investigation dis- closed that California had previously required a check list prior to reaching the range station, somewhat similar to Overseas but had discontinued its use sine such a procedure at that point would divert the attention of the check pilot and impair his watching for other aircraft. Also, the company did not normally require an observer to be stationed in the astrodome , but since the accident this has been required on all training flights. Statements were obtained from a number of eye witnesses to the accident. Some saw both aircraft converging, one headed m an easterly or northeasterly direction and the other in a southeasterly direction. Most witnesses were in agreement as to direction and that neither aircraft deviated from its respec- tive heading Time of observation of both aircraft varied from the time of impact to several seconds before the accident One witness, a pilot flying inbound on the southeast leg of the range, stated that he saw a C-54 (later identified as Overseas) immediately after the collision, and that it appeared to be on a heading of 120 degrees, which corresponds approximately with the inbound magnetic heading of the northwest leg of the range. Examination of the medical records of all crew members involved m this accident revealed no waivers for physical defects. Analysis Overseas was approaching the Oakland range station inbound on the north- west leg which has a magnetic course of 124 degrees. California was homing on the range station on a heading of 75 degrees magnetic. Thus, the angle of convergence was about 49 degrees; this was borne out by a detailed matching of wreckage, paint marks, cuts, and the probable speeds of both aircraft. The resulting computation confirms the above-mentioned angle of convergence. The cockpits of both aircraft were hooded on their left sides. Each carried a safety check pilot on the right. Further, the third crew member in Overseas was supposedly acting as an observer and would be normally stationed in the cabin during straight and level flight and at the astrodome during maneuvers. Since the airplane for some few minutes prior to the collision was observed to be in straight and level flight, it must be assumed that this observer was in the cabin, where his primary duty was to maintain a watch on the left, or the hooded side of the aircraft, for other traffic. Although the observers field of vision supplements that of the safety pilot, it is also reasonable to assume that he would check the right side for traffic. The responsibility of the Overseas safety pilot under these conditions was to maintain a lookout ahead and to the right to avoid collision with other aircraft, since his vision to the left was greatly obscured, Since both air- craft were converging at an angle approximately 49 degrees for some period of time prior to collision, the evidence is clear that had the safety pilot been maintaining such a lookout, he would have definitely seen California on his right. As to why he did not do so, we may only conjecture that he , during a portion of the time, was in the process of going through the required cockpit check prior to reaching the range station or that he may have possibly been engaged in grading the pilot in the left seat or in other duties. Had Overseas observed California converging on its right, it would have been re- quired to give way to that aircraft.7/ As previously stated, California was on a heading of 75 degrees magnetic, which placed the aircraft to the right of Overseas. Ifaus, the safety pilot of California on the right side of the cockpit could not see more than 45 degrees to his left. As there was no observer stationed in the cabin, it is apparent that this flight, could not see Overseas as both aircraft converged on the range station. The fact that a mechanic working in the cabin of California did observe the other aircraft, but too late to alert the crew, is significant Had an observer been on duty, the accident could have been averted In fact during the final stages of convergence both aircraft could have been plainly visible one from the other had safety requirements of adequate lookout from both aircraft been adhered to. Furthermore, had both flights followed their company practices of reporting to the tower immediately prior to arrival over the range station, the tower operator might well have prevented the collision At the Oakland Airport the altitude of the traffic pattern is 1,500 feet, as established by the local authorities and approved by the CAA. Below this altitude all aircraft in the traffic pattern are under the control of the tower operator, whose duty is to assist in maintaining an orderly flow and separation of traffic. Above the traffic pattern altitude, the tower operator does not normally exercise control under VFR conditions. As both flights were on VFR flight plans they were not under control of Air Traffic Control. Thus, neither flight was under any ground control whatever at the time of collision; therefore, responsibility for preventing collision m this case was vested solely in the flight crews. 7/ Civil Air Regulations Section 60.14 (h) Converging. Aircraft con- verging shall give way to other aircraft of a different category m the follow ing order ..... When two or more aircraft of the same category are converging with approximately the same altitude, each aircraft shall give way to the other which is on its right. 8/ Civil Air Regulations Section 43.67 (c) Simulated Instrument Flignt. Aircraft shall not be flown under simulated instrument flight conditions unless* * (c) Such safety pilot at all times has adequate vision forward and to either side of the aircraft, or a competent observer occupies a position in the air- craft so that his field of vision adequately supplements that of the safety pilot Obtained from RareAviation.com. See our selection. Copyright (c) 2004 The Board has stated in reports of previous air collisions that pilots are charged with the highest degree of responsibility in maintaining a lookout for other aircraft. In fact, the Board7s regulations require the utmost pilot vigilance at all tunes, and CAA standards, as published in its Flight Informa- tion Manual, set forth in part that: When flying in Visual Flight Rule weather conditions, (regardless of the type flight plan or air traffic clear- ance), it is the direct responsibility of the pilot to avoid collision with other aircraft," It appears that the hoods installed m both aircraft met the general requirements of the CAAs Manual of Procedure, No, 4-2-1 Ihis reads m parts "The applicant for an instrument rating will furnish a certificated aircraft suitably equipped wixh a proper hood, baffles, cr colored glass, * "The term proper hood5 is construed to mean a hood, which will completely exclude all outside visual reference to the pilot on instruments yet not unduly restrict vision of the safety pilot, agent, or examiner Sufficient visibility to permit clearance for turns in either direction, as well as adequate forward visibility is required. In aircraft having a side-by-side seating arrangement affording inadequate visibility to tne left, a safety observer will maintain a watch on the lefr Such observer must b c in > J uninterrupted aural or interpnone contact with the safety pilot at all times." Overseas, following this accident^ continued to use the same type of hood. The company believes that this type hood offers a satisfactory degree of safety because it permits a reasonable amount of vi sion to the left by the safety pilot a "Bie company further feels that uhen "Bie company further feels that when a competent observer IS carried^ as was the tA.'hAn -Hti nnl lisi nr? r r? case when this collision occurred, rhe re is ample vision ahead and no both sides, The fact rhat Overseas was hooded did not in any way contribute to the accident Overseas is continuing to use a check list prior to arrival over the range station on the initial approach Company policy is to complete this check-off at an appreciable period of time before arrival over the range. Following the accident the CAA recommended that both carriers adopt a different crew arrangement during training flights This called for the safety pilot m the ^ignt seat mo have no other duty than keeping continuous watch ahead and to both siaeso The engineers (jump) seat would be occupied by the cheek pilch who would accomplish grading the trainee and handling the cneck-off. However, Over- seas continued using its former crew arrangement except that the observer is now stationed continuously at the astrodome; this arrangement was acceptable to the CAA. California, immediately after the accident, revised its policy to re- quire that the third crew member or observer on all instrument training flights be stationed at the astrodome. It also changed its type of hood installation, using a vertical slat or baffle type hood, which permits a largely unobstructed field of vision to the lefr by the safety pilot. Later, following the a fore-mentioned recommendation by the CAA., California again revised its crew arrangement, complying with that recommendation in full. On January 3, 1952, the CAA filed a report of violations of the Civil Air Regulations against the safety pilots of both aircraft. Captain Click, (deceased), safety pilot of Overseas, was charged with three violations of the CAR^2/ These are summarized in the violation report, to wit: "While on a six months hood check the safety pilot and third crew member acting, it is assumed, as another observer for aircraft, failed to see the California Eastern C-54 and collided with it." Captain Shope, safety pilozt of California, was likewise charged with three violations of the CAR.12 These are also summarized in the violation report, to wit: "While under an instrument hood during a six months hood check, the safety pilot sitting m the right hand pilot seat failed to provid a third crew member to supplement adequately the restricted vision of the safety pilot." The CAA filed these violation reports for record purposes only. Both the Board and the Administrator, in conjunction with the industry and the military, have had the over-all problem of airspace collision hazard under intensive study for some time, including the function of airport traffic control under VFR conditions. Concerning the latter, the Board is considering a requirement that all simulated instrument (hooded) flights operating in accordance with visual flight rules be under tower supervision at all times when within the airport control zone. Irrespectivo of the lack of tower supervision, however, it is clear to the Board that had the responsible crew members of both aircraft complied with existing Civil Air Regulations and maintained the lookout required, this accident would not have occurred. Findings On the basis of all available evidence the Board finds that: 1. Both carriers, both aircraft and all five pilots were properly certificated. 2. Both flights were operating under visual flight rules from the Oakland Airport. 3. Both flights were for the purpose of giving six-month instrument competency checks, with hoods installed on the left side of both cockpits 4. Overseas carried an observer, as required^ California did not 5. Both aircraft were making simulated (hooded) instrument approaches to the Oakland range station at the same altitude. 9/ These are CAR Sections 60.12 (c), 60.14 (b) and 60.15 10/ These are CAR Sections 43.67 (c), 60.12 (c) and 60.13. 6 The aircraft converged at an angle of approximately 49 degrees# 7 Overseas was a few feet higher than California 8 No evasive action was taken by either aircraft before collision 9. Collision occurred at an altitude of 3,000 feet approximately over the Oakland range static: Probable Cause The Board determines that the probable cause of this accident was the failure of the Overseas safety pilot and/or his observer to observe and so avoid the other aircraft and the failure of Californias safety pilot to carry a qualified observer aboard the aircraft to insure an adequate field of vision BY THE CIVIL AERONAUTICS BOARD: DONALD W. NYROP s/ OSWALD RYAN s/ JOSH LEE /s/ JOSEPH P. ADAMS CHAN GURNEY SUPPLEMENTAL DATA Investigation and Hearing The Civil Aeronautics Board received notification of the accident on November 17, 1951, at approximately 1100, by telephone from CAA Communications Los Angeles, California, and immediately initiated an investigation in accordance with the provisions of Section 702 (a) (2) of the Civil Aeronautics Act of 1938, as amended. A public hearing was ordered by the Board and held at Oakland, California, on December 13, 1951. Air Carriers California Eastern Airways, Inc., was incorporated under the laws of the State of Delaware m 1946 and operated as an exempted air freight carrier until 1948. On August 1, 1950, the company was granted a prime contract by MATS (Military Air Transport Service) to fly passengers and, or, freight on the Pacific Airlift over routes designated as "Mid Pae" and was engaged m this operation on November 17, 1951. The company holds Letter of Registra- tion No. 0-14 of the Civil Aeronautics Board, dated October 3, 1947, and was issued an air carrier operations certificate No. 6-10 (c) on February 19, 1951. Overseas National Airways, Inc., was incorporated under the laws of the State of Delaware m 1950. The company was issued Letter of Registration No. 806 by the Civil Aeronautics Board on August 12, 1947, but since the carrier's aircraft were being operated by Transocean Air Lines, under agree- ment, the Letter of Registration was cancelled. However, after Overseas National obtained control of its aircraft, it applied for, and the Board re- issued, the Letter of Registration on April 25, 1950. The company was also issued air carrier operating certificate No. IR-5 by the Civil Aeronautics Administration on September 12, 1947. This carrier also has a contract with MATS (Military Air Transport Service) to fly passengers and/or freight m air lift operations. Flight Personnel Captain Ralph A. Shope, age 40, was employed as chief pilot by California Eastern Airlines, Inc., on March 3, 1951- He started flying m 1934 and sub- sequently instructed Army cadets; later he flew for TACA, TWA-ATC during World War II and for KLM and SAS until March 1951, acting as pilot and pilot navigator. His total flight time on November 17, 1951, was approximately 11,225:20 hours, of which 4,732:59 hours were in DC-4 aircraft. His total instrument time was 1,005:55 hours. Captain Shope held a valid airline transport pilot and flight instructor certificates, and had passed his last physical examination on September 6, 1951. Captain Winfield B. Firmer, age 40, was employed by California Eastern Airlines on August 1, 1951. His flight training started m 1928. He was a pilot instructor for the U. S. Air Force m 1943 and subsequently flew for ATC and other military services. During 1950-51, Captain Kinner was a pilot for several irregular air carriers. His total flight time on November 17, 1951, was 5,000 hours, 3,500 of which were in DC-4's. His total instrument time was approximately 350 hours. He held a valid airline transport pilot and flight instructor certificate, and had passed his last physical examination May 1, 1951. Captain Marion Harvey Click, deceased, 31, Overseas National Airways assistant chief pilot was employed by the company on June 16, 1950, as a captain, He received his early flight training in the U. S. Air Force and thereafter as pilot and captain for several air carriers. His total flight time was 7,871 hours, of which 5,028 hours were m DC-4 His total in- strument time was approximately 617 hours. Captain Click held a valid airline transport pilot certificate, and had passed his last physical examination on July 13, 1951. He also held a letter of authorization from the Civil Aeronau- tics Administration to act as company check pilot. Captain Warren Cecil Gessner, deceased, age 27, was employed by Overseas National Airways on June 16, 1950, as a first officer, and promoted to captain on December 4, 1950 He had received his flying training in the U. S. Navy and later with Alaska Airlines, Near East Transport, and Westair Transport. His total flying time was 3,590 hours, and approximately 1,900 hours were m DC-4 aircraft. Captain Gessners total instrument time was 652 hours. He held a valid airline transport pilot certificate and had passed his last physical examina- tion on May 7, 1951. Captain Hammond Garrard, deceased, age 32, was first employed by Overseas National Airways on July 6, 1950, as a first officer, and was promoted to captain on July 17, 1950, but was furloughed until November 15, 1950o His flight training was obtained in the U. S. Navy; later he piloted for California Eastern and with Capital Airlines. He had a total of 5,879 hours and 3,100 hours of this time was m DC-4 aircraft. His total instrument time was 330 hours. Captain Garrard held a valid airline trans- port pilot certificate and had passed his last physical examination on May 14, 1951. The Aircraft N 4002B was a DC-4, and as of November 16, 1951, had a total of 16,435 hours. Flight time since its last overhaul was 6,484 hour; All historical and maintenance records pertaining to the aircraft were found in order* California Eastern Airways had leased N 4002B from TACA Airlines on April 5, 1951. N 79992, also a DC-4, had a total time of 5,257 hours since last overhaul. The aircraft was obtained by Overseas National Airways from the U. S. Air Force on a lease agreement dated May 2, 1947. It was subsequently sub- leased to Transocean Airlines, but this lease was later terminated on January 9, 1950. The aircraft was first operated by Overseas National Airways on August 16, 1950. - ii - Distance and Closing Diagram Path of Overseas Air Collision of 2 DC-4s Speed 140 m ph 78 Oakland Calif , Airport Nov 17. 1951 124 M I 16 miles , 58 miles o C / / (A. 715 miles Impact Site 75 M App 3000 feet I 43 miles above Oakland Range Station 53 Path of Coliforma Speed 17 0 m p h Mtachment A 2 86 miles 13786 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: June 30, 1949 Released: June 30, 1949 CHICAGO AND SOUTHERN AIR LINES , INC.---NEW ORLEANS, LOUISIANA--- MARCH 13. I9U9 A Chicago and Southern Air 3 captain elected to NC 53102, operating as Flight Lines DC-4, approach lights. The instrument Maiquetla, Venezuela, 500 from continue on IIS for a land- via Havana, Cuba, ing procedure practice approach. The to New Orleans, Louisiana struck several first officer stated that as they neared trees while making an ILS (instrument the middle marker he noticed that the landing system) approach to Molsant Air- airplane seemed to be much lower than the port, New Orleans, at 2^24C^ March 13, glide path receiver indicated and he no- 1949. The airplane, although damaged tified.the captain that they were too considerably, was still controllable and low. Power was immediately applied and flight was continued to a normal landing landing gear retraction begun. Almost on Moisant Airport without injury to any- simultaneously the airplane began strik- one on board. ing the tops of cypress trees 90 to 100 Flight 500 departed from Havana, Cuba, feet in height. It then struck the com- on schedule on an instrument flight plan. pass locater pole, approximately 60 feet The flight crew consisted of Captain high, located at the middle marker, 3,485 Lloyd. Rowe Davidson, First Officer Jack feet from the approach end of the runway. Dillard Payne and Radio Officer Forest E. As soon as the captain realized the air- Scott. When they arrived in the New Or- plane was still controllable, he lowered leans area weather conditions were re- the landing gear and continued straight ported as ceiling indefinite 800 varia- ahead to a normal landing on Runway 10. ble, overcast lower broken, visibility 3 Upon arriving at the loading ramp the 11 lies, light rain, smoke and fog. New passengers deplaned, following which the Orleans approach control cleared the aircraft was towed to a hangar and placed flight to the Moisant range station at under guard. No one was allowed on board 2,500 feet and when it reported over the pending arrival of rhe Boards investi- range station, cleared It to the outer gator . marker for an ILS approach. Immediately after the accident the The aircraft was a little above ap- crew of Flight 500 reported the ILS glide proach altitude over the outer marker2 path unreliable and the tower then issued and flight was continued a short distance a notice to airmen that the glide path at out the ILS approach leg in order to lose Molsant Airport was inoperative. When an altitude. Following a normal procedure immediate check of the ILS ground in- turn, in which the flaps were lowered 15 stallation revealed it to be operating degrees and the airspeed was reduced to normally, the notice to airmen was lifted- 140 mph, the landing gear was lowered. The tower then solicited checks from in- The airplane passed over the outer marker coming flights and at <241, 17 minutes inbound at an altitude of approximately after the accident occurred, an Eastern 1,040 feet with the glide path and local- Air Lines flight made an ILS approach izer well centered, iower was then ad- and landing and reported that everything justed to maintain an airspeed of 130 mph. seemed normal. The first officer advised intermittent Subsequent to the accident five cap contact at 700 feet and at 500 feet re- tains of Chicago and Southern flights ported that be could see the runway and who had made simulated ILS approaches to 1A11 times referred to herein are Central Stand1 ** ard and based on the 24-hour clock Chicago and Southerns ILS mlnlimuns for Molsant 2 Airport, New Orleans, were celling 300 feet, visibil- St92 miles from the approach end of Runway 10. ity 3/4 mile. --- 15011 (1) III New Orleans reported difficulty with the to other means at the crews disposal for glide path. On March 14 a CAA DC-3, es- determining the flights altitude would t pecially equipped for flight checking ILS have precluded descending so dangerously ground installations, was flown to New low during the approach. The altimeters Orleans. Seven flight checks were made were properly set and as far as could be of the ILS equipment at Moisant Airport determined were functioning normally. on March 14, 15 and 16, and it was found Moreover, the crews testimony indicates to be functioning normally in every re- that not only were the runway and ap- spect. proach lights visible after reaching the In view of the fact that ILS malfunc- 500-foot altitude, but also that there tioning was reported by Chicago and was no scud or other obstructions to Southern pilots only, three of their air- visibility during the last portion of the planes (one DC-3 and two DC-4s) were taken approach and at the time of impact with from schedule as they came into New Or- the trees. leans on March 15 and were flown down the As a result of this accident the Civil ILS approach path. It was found that the Aeronautics Administration restricted ILS receivers in all three airplanes were Chicago and Southerns operations to lo- not properly calibrated. calizer onZy minimums during the short On March 16 the glide path receiver period that its glide path receivers were was removed from the airplane involved in being recalibrated. the accident and installed m another The airplane, carrier and crew were Chicago and Southern DC-4 for checking. properly certificated for the flight in- Captain Davidson piloted the airplane on volved. Captain Davidsons service with this test and simulated as nearly as pos- Chicago and Southern covers a period of sible the approach he had made the night nearly 12 years, His total pilot time of the accident. This flight showed con- is approximately 15,000 hours 2,500 of clusively that the ILS receiver was out which were accumulated m the type of of calibration and that the cross-pointer aircraft involved. He stated that he indicator did not give sufficient warning had made more than 100 actual and simu- to the pilot when the airplane was below lated ILS approaches and that approxi- the glide path. Subsequent laboratory mately 100 of them had been with First tests confirmed that this receiver was Officer Payne. On March 16, 1949, he not calibrated properly. was given a thorough flight check in a Testimony of Captain Davidson and First DC-4 at New Orleans in which he demon- Officer Payne indicated that their alti- strated complete competency to conduct meters registered in excess of 250 feet instrument flight and ILS approaches. immediately prior to Impact with the First Officer Payne had been with Chicago trees. The station barometric pressure, and Southern since November 1, 1945. He as furnished the flight by the tower just had flown approximately 2,600 hours, prior to the approach was 29.99. Exami- which included about 790 hours in the nation of the aircrafts altimeters sub- type of aircraft involved. sequent to the accident revealed them The Board determines that the prob- both to be set at 29.99. Furthermore, able cause of this accident was failure these instruments were removed from the of the flight to maintain sufficient al- aircraft and appropriate tests conducted, titude to clear obstructions during a all of which showed them to be function- simulated ILS approach. ing normally. There seems to be no doubt that the BY THE CIVIL AERONAUTICS BOARD: airborne ILS equipment in NC 53102 was calibrated in such a manner that if the /$/ JOSEPH J. O'CONNELL, JR. pilot depended solely on its readings in !sf OSWALD RYAN making an ILS approach to the minimum Isl JOSH LEE altitude, he would be misled as to his Isl HAROLD A. JONES position. However, sufficient alertness Is! RUSSELL B. ADANS ---15011 From CIVIL AERONAUTICS BOARD CCIDENT INVESTIGATION REPORT Adopted? October 17, 1951 Released: October 22, 1951 COMPANIA CUBANA DE VI AC I ON S. A. AND U. S. NAVY, KEY WEST, FLORIDA, APRIL 25, 1951 THE ACOI DENT separation from another aircraft climbing to At 1149 EST1 April 25, 1951, a DC-4 air- 6,000 feet At 1114, Miami ARTC forwarded craft, Cuban registry CU-T188, operated as to PAA Flight Watch by interphone, the Trip No 493 m scheduled service between following message ATC clears Cubana 493 Miami, Florida, and Havana, Cuba, by cruise and maintain 4,000 This clearance Conipania Cubana de Aviacion, S A , 2 3 * 3 * was in- was delivered to the flight by PAA radio volved m an air collision with a Navy SNB at 1119, at which time the flight advised aircraft, No 39939, which was engaged m an that it was at 2,000 feet, estimating Key instrument training flight West at 1148^ and was leaving 2,000 feet The collision occurred over the westerly climbing to 4,000 feet This was the last side of the Naval Station at Key West, message received from the aircraft Florida, at an altitude of approximately On the morning of the same day a twin- 4,000 feet All 34 passengers and the crew engine Eeechcraft, Navy designation SNB of five aboard the DC-4, and the four per- No 39939, was scheduled for a simulated in- sons consisting of an instructor, two stu- strument training flight from the U S Naval dents and a radioman aboard the Navy SNB, Air Station,5 Key West, Florida, at 112' lost their lives The flight, to be conducted under visual flight rules, had no altitude or area assign- HISTORY OF THE FLIGHT ment other than that necessary to accomplish Cubanas Trip No 493 departed Miami at the training mission One portion of the 1109, April 25, 1951, via the direct Miami- mission requires a flight inbound on the Key West Control Area Extension The crew east leg of the Key West Radio Range on a of five consisted of Javier Z Bazan, cap- heading of 250 M , at an air speed of 14 I tain, Jesus F Pacheco, first officer, Pablo knots Upon recognition of the cone, the Valencia, purser, Pedro Martenezmoles, stew- pilot proceeds outbound on the west leg of ard, and Orlando Salas Fernandez, observer the range on a heading of 279, reduces Mr Fernandez was also Chief Pilot of Cubans speed to 105 knots, lowers the landing gear A request for clearance had been filed by and descends to an altitude of 1,300 feet A Pan American Airways^ with the Miami Air procedure turn is then made and the pre- Route Traffic Control (ARTC) at 1023, re- scribed pattern followed for a simulated in- questing an altitude of 6,000 feet The strument approach to Boca Chica Airport flight, while waiting m line for takeoff, (See Appendix I) was cleared by ARTC through the Miami Tower The aircraft departed the air station to Havana to cruise at 4,000 feet, but was ramp with Pilot-Instructor Robert Lowler instructed to maintain visual flight rules Stuart, Lt (jg), USN, occupying the left until further advised in order to provide pilot seat, Eugene Samuel Bardsley, Ensign, USNR, occupying the right pilot seat, and Key West, Florida, is a reporting point for 1 All times referred to herein are Eastern Cubans but not a scheduled stop Standard and based on the 24-hour clock 5 This air station is at Boca Chica Airport 2Hereinafter referred to as Cubans * which is located approximately 5 6 statute miles 3 Pan American Airways acts as U S Agent for northeasterly from the Key West Radio Range Sta- Cabana at Miami tion Francis Lavelle Beady, Midshipman, USN, and continued for seven days involving nearly Alfred Leroy Gasser, Aviation Radioman, all of the Key West Naval Station components First-class, occupying undetermined seats and local Coast Guard units In general, the in the aircraft's cabin The Navy Tower operations consisted of recovery of bodies cleared the flight and takeoff was made at and personal effects and subsequent identi- 1126 After takeoff, tower frequency was fication and care The search for and sal- cleared and since the subject aircraft was vage of the wrecked aircraft consisted of on a standby status for Air-Sea Rescue pur- and resulted in poses, a routine radio contact was made with the Ground Control Intercept Unit at 1128 1 Recovery and identification of the 39 However, no altitude or position was given bodies from the DC-4 and two from the SNB This was the last known contact made with 2 Thorough search of the sea bottom this aircraft within a radius of approximately 500 yards At 1149 the Cubana DC-4, on a southerly around each wrecked aircraft heading, and the Navy SNB, on a westerly 3 Search of other extensive areas where heading, collided at a point over the west- witnesses reported seeing objects falling erly edge of the U S Naval Station at an into the water estimated altitude of 4,000 feet As a re- 4 Recovery of approximately 88 per cent sult, the Navy aircraft crashed into the of the structure of the Cubana DC-4 water just west of the Naval Station The 5 Recovery of approximately 80 per cent Cubana aircraft, however, continued on for of the structure of the Navy SNB some distance before entering a left bank 6 Use of 20 Navy divers, a total of 680 which became progressively steeper until the hours of actual diving time aircraft assumed a nose-down attitude In this position, it crashed into the ocean ap- All recovered portions of the SNB were proximately 1 7 miles southeast of the point located approximately 548 yards off shore of collision west of the U S Naval Station In this same area were found all the recovered por- INVESTIGATION tions of the DC-4 left wing outboard of Shortly before the collision the Cubana No 1 engine nacelle Practically all the DC-4 was observed by ground witnesses about remaining portions of the DC-4 which were one mile north of the center line of the recovered were found m about 25 feet of direct Miami-Key West Control Area Exten- water approximately 1 7 miles southeast of sion The altitude was estimated as 4,000 the point of collision feet, and the heading approximately 223 M Among the recovered portions of both air- At about the same time and approximately the craft, sufficient evidence was found to estab- same altitude, the Navy SNB was observed on lish the position of the aircraft relative to the east leg of the Key West Radio Range, each other at the moment of initial impact approaching the station on a heading of The right propeller of the SNB had deep gouges about 250 Witnesses saw the two aircraft on the leading edge of both blades The sec- collide at a point approximately 1 6 miles tion of the DC-4 left wing recovered with the west of the Range Station and just north of SNB wreckage showed evidence of having been the on-course signal The U S Naval Sta- cut by a revolving object at wing stations tion Duty Officer At Key West was informed 588 1/2 and 540 1/2, the cutting action being ot the accident at 1150 However, the iden from the front to the rear of the wng and tity of the aircraft was not known at this parallel to the longitudinal axis of the DC-4 time By 1200, it became apparent to the Hie cut on the DC-4 left wing at station station that the crash was one of major pro 588 1/2, which was made by one blade of the portions and steps were irrarediately initi- right propeller of the SNB, was the first ated to activate all rescue and salvage fa- contact between the two aircraft The cutin cilities within the area Search and sal- the DC-4 left wing at station 540 1/2 by vage operations were begun immediately and the second blade of the SNB right propeller, shortly thereafter the aircraft involved and the contact of the tip and leading were identified The salvage operations edge of the DC-4 left wing with the ---38544 right side of the SNB fuselage, followed operation was indicated At 1150 on the almost simultaneously There was evidence same date, immediately after the accident, of subsequent impact between the two air- the aural and visual monitor indicated nor- craft, however, the damage was of such a mal operation nature that it was not possible to determine The Key West weather at 1124 was reported any sequence of events The SNB propeller as scattered clouds at 2600 feet, 15 miles cuts m the DC-4 left wing indicated that visibility, temperature 81, dewpoint 68, the angle between the longitudinal axis of wind east-northeast 13, altimeter setting the two aircraft at the moment of impact was 30 09 Two-tenths sky coverage was recorded approximately 110 (See Appendix II) at 1124 and 1225, however, the pilot of Na- The Cubana DC-4 and its crew were prop- tional Airlines Flight 457, Miami to erly certificated in accordance with the re- Havana, stated that when he passed over Key quirements of the Cuban Civil Aeronautics West at 1141 at 8000 feet, the weather was Administration The aircraft was equipped clear and unlimited The suns altitude at to receive and transmit on all radio fre- the L S Naval Base at 1149 on the date of quencies required for the route involved, the accident was 76 degrees, 54 minutes at and at time of departure was loaded within 138 azimuth At 1220, it reached the peak the allowable gross weight and center of altitude of 80 degrees at 180 azimuth gravity limits The flight was properly Neither the weather nor the suns position dispatched, and cleared by the Miami ARTC is considered a contributing factor in this m accordance with Instrument Flight Bules accident The route of this flight, as prescribed by Cubanas Operations Manual and the ARTC ANALYSIS clearance, was over the Control Area Exten- The heading from Miami to the Key West sion direct from Miami to Key West, recently Radio Range Station, via the Control Area established and published in the Civil Aero- Extension, is 223 0 M From the Key West nautics Administration Airmans Guide, Vol- Range to Havana, the heading is 197 M ume 5, No 24, dated February 13, 1951 The Shortly before the accident, ground wit- magnetic course from Miami to Key West on nesses observed a four-engine aircraft about this airway extension is 223 a mile north of the center line of the Miami- The Navy aircraft was properly scheduled Key West Control Area Extension proceeding and dispatched Records indicate that it on a heading of approximately 223 and at an was loaded within the allowable gross weight estimated altitude of 4,000 feet While no and center of gravity limits prescribed by witness was found who followed this aircraft the U S Navy They indicate further that on to the point of collision, it must be the aircraft was equipped to receive and presumed to have been the Cubana aircraft transmit on 3265 kilocycles and 143 23 since its estimated time of arrival over Key megacycles, plus standard radio range fre- West was 1148, and no other aircraft of this quencies type is known to have been in the area at For operation under simulated instrument that time From the testimony of witnesses, conditions, the aircraft was equipped with it would appear that the collision occurred orange-colored plexiglass, detachable wind- while the DC-4 was m a gentle left bank or shield panels covering all sections of the had just leveled out on the new Havana head- windshield but not the sliding window panels mg of 197 M on either side of the cockpit A student Shortly before the accident, a Navy SNB under instruction wearing the proper colored was observed at an estimated altitude of goggles is unable to see through the wind- 4,000 feet approaching along the east leg of shield, but retains the usual vision within the Key West Radio Range, which heading to- the cockpit however, the visibility of the ward the Station is 250 M Since this instructor and other crew members is unre- training flight involved simulated instrument stricted approaches on the Key West Radio Range, it The Key West Radio Range was given a vis- is assumed that such an approach was being ual and aural check at approximately 1000 on made at the time of the collision This as- the day of the accident, at which time normal sumption is further supported by the fact that the collision occurred at a point where Administration, and the flight was properly the aircraft would normally have been shortly dispatched from Miami on an IFR Flight Plan after over-heading the Range Station As no 3 The Navy aircraft was airworthy, prop- evasive action by either aircraft was ob- erly dispatched, and its crew qualified for served, it is apparent that the crews either the subject flight did not see each other or saw each other too 4 The weather m the Key West area at late to avoid collision 6 the time of the accident was clear and un- limited FINDINGS 5 The flight of each aircraft was rou- Upon the basis of all available evidence, tine and according to plan up to the time of the Board finds that collision 6 The collision resulted in the destruc- 1 The air carrier, Compama Cubana de tion of both aircraft and the death of all Aviacion, S A , is authorized to engage in occupants air transportation of persons, property, and mail between Havana, Cuba, and Miami, PROBABLE CAUSE Florida, by Permit to Foreign Air Carrier, The Board determines that the probable Docket No 1887, issued by the Civil Aero- cause of this accident was failure of crews nautics Board of both aircraft to maintain sufficient vig- 2 The aircraft and crew were currently ilance under VFR conditions to prevent a certificated by the Cuban Civil Aeronautics collision BY THE CIVIL AERONAUTICS BOARD The Chairman of the Board, m a letter to the DONALD W NYROP Administrator of Civil Aeronautics, suggested that appropriate personnel of the Civil Aeronau- OSWALD RYAN tics Administration and the Civil Aeronautics JOSS LEE Board review present Air Traffic Control proce- JOSEPH P ADAMS dures and existing operational practices m this area CHAN GURNEY ---38544 Supplemental Data INVESTIGATION AND HEARING on December 1, 1935 He had a total time of The Civil Aeronautics Board Miami office 9,451 hours, of which 363 hours were m the type of equipment involved He held Air- v,as notified at 1216, April 25, 1951, by the line Pilot license No 71 with 30 rating is- Miairi Civil Aeronautics Administration Com- sued by the Cuban CAA His last physical munications Station that Cubana's Flight No examination was accomplished November 18, 493 was overdue at check point, Key West, 1950 Florida At 1340, additional information was received that an air collision had occurred in the Key West area at 1149 The Boara im- CUBANA IRCRAFT mediately initiated an investigation m ac- The Cubana aircraft was a C54B, Serial No cordance with the provisions of Section 10368, Cuban registration CL-T188, manufac- 702 (a)(2) of the Civil Aeronautics Act of tured by Douglas Aircraft Company m August 1938, as amended A public hearing was held 1944 for the LT S Army Air Force It was m Key West, Florida, May 16, 17, and 18, purchased by the Pan American Grace Airways, 1951, as part of the investigation Inc , and modified on April 13, 1947, by the Douglas Aircraft Company to a DC4-B, after AIR CARRIER having accumulated l,970 hours flight time Compania Cubana de Aviacion, S A , is a The aircraft was purchased from Pan American Cuban corporation with headquarters at Grace by the Pan American World Airways on Havana, Cuba, and has been authorized by the November 22, 1947, and on April 1, 1948, was Republic of Cuba to operate m scheduled air leased to the Cubana company with an option service since October 8, 1949 CM May 15, to purchase, which option was exercised by 1946, Cubana inaugurated scheduled service Cubana on August 1, 1948 The aircraft was between Miami, Florida, and Havana, Cuba, m operation on the various routes of the under Permit to Foreign Air Carrier, company until the oay of the accident The Docket No 1887, issued by the Civil Aero- total accumulated time was 13,218 hours nautics Board NAVY AIRCRAFT FLIGHT PERSONNEL Captain Javier Z Bazan, age 50, held cur- The Navy aircraft was a Beechcraft, Model rent Republic of Cuba CAA Airline Pilot Li- SNB-5, carrying Bureau No 39939 It was cense No 24 with 30 rating His total time equipped with two Pratt & Whitney engines, as pilot was 12,158 hours, 1317 hours of Model R-985-AM-3, and with Hamilton Standard which were m the type of equipment involved propellers, Model No 2D30-237 Navy records His total instrument time was 370 hours His indicate the aircraft to have been in an last physical exami nation by the Cuban CAA airworthy condition and to have accumulated Flight Examiner was accomplished March 18, a total time of 993 hours 1951 He had been employed since September 2, 1938, by Cubana NAVY FLIGHT PERSONNEL First Officer Jesus F Pacheco, age 29, Robeit L Stuart, Lt (jg) USN, (Instruc- held current Republic of Cuba CAA Airline tor), Francis L Ready, Midshipman USNR, and Pilot License No 287 with 3P rating He Eugene S Bards ley, Ensign USNR, were quali- had been employed by Cubana since October 13, fied naval aviators attached to the Fleet 1941, and had accumulated a total of 4,557 All-Weather Training Unit, Atlantic The hours, of which 2,791 hours were m the type physical examinations of these men showed no of equipment involved His last physical waivers or defects Lt Stuarts last phys- examination was accomplished March 21, 1951 ical was accomplished on December 11, 1950 Orlando S Fernandez, chief pilot since The fourth member of the crew was A L March 19, 1949, was first employed by Cubana Gasser, Radioman, First-class, USN 38544 ft Probable Path of DC 4 4? c? $ u the load was distributed witn respect "h ncr-cr'*iric^Le-j -air c-'TrJ.er* to a pany ope^irg Ir commerce w thouc a ce^Llfre to the center of gravity- within of public cDnve^ferce ard necess ry, end Is comncnly approved limits* referred to as a ncn-scleduled air carre^ ---17671 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: June 29, 194. Released: June 30, 1948 EASTERN AIR LINES---NEAR BAINBRIDGE, MD., MAY 30, I9U7 The Accident went down vertically or nearly so and without rotation. Clear weather existed Eastern Air Lines Flight 605, a DC---4, at the time and place of this accident NC 88814, en route non-stop from Newark, and at the 4,000-foot level there was no New Jersey, to Miami, Florida, crashed restriction to vision and the air was near Bainbridge, Maryland, about 1741,1 smooth. May 30, 1947, fatally Injuring all 53 The Boards aircraft was landed at the occupants and demolishing the aircraft nearest airport (Phillips Field, Aber- deen) some 15 miles distant and the per- History of the Fl ight sonnel aboard including the Chief of the Flight 605 carried 48 revenue passen Safety Bureaus Accident Investigation gers, one Infant, a crew of four, and Division immediately went to the crash cargo. An Instrument flight plan sped site. Investigation started at once and Tying a cruising altitude of 4,000 feet other Safety Bureau personnel arrived was filed and approved. The plane was shortly afterward. Full facilities of away from the ramp at its scheduled de- the nearby Bainbridge Naval Training parture time of 1655 and off the g-round Station were made available to investi- at 1704. gators and other Interested parties, al- Position reports were made over lowing almost immediate guarding of Metuchen, New Jersey, at 1,000 feet al- wreckage, transportation, communication, titude and Philadelphia, Pennsylvania, housing, and technical assistance. at 4,000 feet altitude, at 1710 and 1727 Impact with the ground was about 2 respectively. The 1727 message included miles east of Bainbridge, on Amber 7 an estimated time of arrival at Baltimore Airway, in a moderately to densely wooded as 1749. No message suggesting trouble area with trees 60-70 feet high. The was received. aircraft broke up Into a large number of At approximately 1741 a number of per- pieces which were strewn irregularly over sons in various locations on the ground an area roughly 500 feet long and 150 near Bainbridge saw the aircraft enter a feet wide with the explosive-like vio- dive which became progressively steeper lence common to high-speed crashes The until it passed from their view behind direction of the long axis of this area, trees or terrain. from the initial Impact end, was about 90 or nearly ea^t, and opposite to the Investigation flights original westerly course. A quite clear-cut path of trees, broken at Two Civil Aeronautics Board personnel, decreasing heights, indicated that the pilot and copilot of a Board aircraft plane came through them at an angle of cruising at 4,500 feet en route from New 28-30 below the horizontal. Near both York to Washington, witnessed the dive sides of this line of broken trees were and crash. As they were about 3 miles closely-spaced unbroken trees. Examina- behind the airliner, at about the same tion of the wreckage indicated that the altitude, and flying In almost the same plane was inverted at impact with its direction, they were unable to estimate left wing low. A flash fire which fol- accurately the angle or path of descent, lowed burned leaves and foliage and to them it appeared that the aircraft scorched tree trunks throughout the wreckage-strewn area, there was no sus- ^11 times referred to herein are Eastern Standard tained or concentrated fire. (A detailed and are based on a 24*hour clock. sketch of the crash site is attached.) ---19491 (1) All major portions of the horizontal No significant discrepancies from orig- tail surfaces were found in a similarly inal witness statements were found heavily wooded region some 300 yards Those statements indicated, in consensus, west of the crash site. These pieces that the aircraft started a dive from a were concentrated in a comparatively^ cruising level of about 4,000 feet, that small area under the path of final in- this dive became increasingly sharper, verted approach. became vertical and was beyond the ver- Investigational personnel of&he tical as the aircraft passed from their Safety Bureau were assigned definite sight just before hitting the ground missions and were assisted by represen- Throughout this testimony there is a tatives of other Government agencies and strong suggestion that the path of the the aircraft industry. To " expedite the aircraft was like the almost completed investigation in an orderly and thorough first half of an outside loop. Only one manner, specialized groups were formed of the eight witnesses thought he saw a to examine power plants, structure and portion of the tall surfaces leave the eyewitnesses. aircraft before the dive started. How- All parts of the engines, nacelles 9 ever, two other witnesses thought that propellers and their 'associated controls the aircraft made a number of longitudi- that could be found were examined. Al- nal oscillations (alternately going up though one propeller blade tip approxi- and down and described as "like steps) roately one foot long was never located before the dive started. Still another subsequent tests conducted on the re- thought that the aircraft went up mainder of the blade indicated conclu- slightly before starting down. Several sively that it had broken upon Impact witnesses were sure that the tall sur- and not m flight Further, it was re- faces disintegrated and left the air- liably reported that this blade tip was craft as it neared the ground, while carried off by an unknown person. possibly only 600 feet high. Examination of the aircraft structure Exhaustive investigation continued for and inspection of parts were conducted months. Field and Washington investiga- at the scene, Later, parts were removed tors of the Board probed manufacturers to the Bainbridge Naval Station to facil- records, maintenance reports and mainten- itate a more complete identification, ance methods of air carriers using this evaluation and a reconstruction of the model aircraft, and the maintenance empennage All but two pertinent parts history of the subject aircraft. were found at once and they were recov- Discussion ered shortly. All parts were studied individually and collectively in an at- The flight was dispatched properly tempt to deduce the sequence of failures from Newark. The flight crew was cur- and so arrive at the point of initial rently certificated and, qualified over failure. Certain failed parts were sub- the route. Weather was excellent and jected to laboratory tests in an effort did not contribute to the accident. In- to determine the nature of failure. In vestigation of the power plants can be addition, reports and comments were so- summed in the statement that nothing was licited and received from many interests found to indicate or even suggest that of the air industry. there had been any malfunctioning of any Statements were obtained from numerous component of any power plant. eyewitnesses to the aircrafts path im- A study of the distribution of the mediately prior to the accident. During wreckage indicates that parts of the em- a subsequent flight by a Board aircraft pennage left the aircraft at about the m simulation of the flight of the same time, and at low altitude, otherwise crashed ship, in the same direction, at their resting places would have been far the same altitude and during the sajre more scattered. No part of the aircraft type of weather, qualified technical was found anywhere except m the areas personnel questioned key witnesses at Of the main wreckage or of the tail those witnesses original positions to wreckage. check upon the authenticity and plausi- Work of the structures team was ardu- bility of their original statements as ous and involved because many hypotheses to their observations of the flight path as to the initial failure were proposed. - 19491 Exploration of these many hypotheses be- could be the possibility of flutter of came complicated and highly technical. the rudder tab causing the horizontal For that reason they will be discussed tail surfaces to VxDate sufficiently to in considerable detail disintegrate In order for this to be true, there would have been evidence of Theories fatigue and flutter m the attachments 1 Since the 1/4-mch-diameter shear of the rudder tab hinges to the rudder pin in the left outboard elevator hinge but a careful metallurgical examination was not located and as a similar air- of each of the three attachments of the craft had experienced severe vibration rudder tab to the rudder disclosed no of the tail group because of this pin such evidence The breaks were evi- dently the result of impact. being out, it was suggested that pos- sibly this was the cause of the unport- (c) None of the spar breaks for both ing2 of the elevators and the destruc- elevator and stabilizer showed any signs tion of the airplane However, there is of fatigue strong evidence to indicate that this 3. Possibly an explosion in the s tab- shear pin was intact and in place at the ilizer tips started the chain of events time of the unporting because leading to the crash, This theory has (a) Otherwise, there would not have been advanced because First, an in- been a symmetrical impression made on flammable fluid had once been Inside the both inboard sides of the female part of stabilizer as shown by the presence of a the end of the hinge by the ball bearing residue still in the stabilizer tip, race of the eyebolt second, the distance between the attach- (b) The shear pin had to be intact ing bolt holes of the attaching angle of and in place when the elevator was pulled the stabilizer tips was greater than the to the right sufficiently to bend the corresponding distance of the bolt holes stabilizer spar on the attaching angle of the stabilizer (c) The shear pin had to be Intact end, and third, the end rib of the left and in place when the elevator was un- stabilizer was bent outward This the- ported since otherwise the severe de- ory may be discounted because formation of the elevator hinge casting (a) It is unlikely that even if there by the eyebolt could not have occurred. were an explosive mixture in one of the (d) Also, there is no evidence of stabilizer tips, it would necessarily be wear in any of the parts resulting fro: II in the other stabilizer tip an upward and downward movement as would (b) There must be an ignition source necessarily be true if this shear pin to set off a gaseous explosion mixture had been missing. and, since the airplane is bonded and 2 Possibly the disintegration of the the hinge grounded, it is not apparent horizontal tail surfaces was due to how a gaseous mixture could be exploded flutter induced by either the elevator Furthermore, in the unlikely event of tabs or the rudder tab. This theory may such ignition, it is Improbable that the be discounted since other stabilizer end would have been set (ax The elevator tabs are controlled off simultaneously. (c) It is quite evident that, If there by an irreversible mechanism and the were such an explosion intense enough to tabs were still attached to the eleva- shear the aluminum alloy under the bolt tors, with almost no play at any of the heads of the attaching angles of the attaching joints or In the actuating stabilizer tip, it would surely have system broken and flattened the thin and weaker (b) The rudder tab was found with the stabilizer ribs. However, the stabilizer wreckage of the horizontal tail surfaces ribs near the tip end of the left stabi- and this was due to its having been hit by the left elevator and knocked free lizer indicated almost no sign of damage from the rudder However, there still or deformation. (d) The residue was from a cleaning 2 fluid used approximately 3,000 hours be- Unp or ting* Is the unbalancing of rhe balance por tier of the elevator by an aerodynamic force fore this accident to remove paint. It is reasonable to assume that if there 7 Another theory as to the cause and had been a gaseous inflammable mixture subsequent sequence of failures of the in the stabilizer, it would have been horizontal tail surfaces is scavenged from the stabilizer during the Possibly the first point of failure ensuing 3,000 hours of flight. occurred in the outside torsion box of 4. Shortly after this accident one the right elevator The outside right theory attributed It to an unknown ma- elevator hinge had the elevator casting chinists having counterbored a pin belt still attached to the eyebolt, which in too deeply, causing the pin to fail turn was attached to the hinge by the This theory developed due to the fact shear pin The underside of the eyebolt that one of the attaching bolts of the had scuffed the casting. From these hinge to the stabilizer spar was found markings it is concluded that the ele- in the immediate area of the horizontal vator tip outboard from the inside edge surfaces This bolt appeared to have of the casting had been free and was very little shear area between its shank buffeted about by the air so that the and head The head is of the internal convolutions of the elevator tip in space wrenching type, (NAS 144) However, made these deep Impressions on the cast- this theory is discounted because ing as the tip rotated about the eyebolt. (a) Tension tests were made on the However, In order for these identations internal wrenching type of the hinge at- to have occurred, there must have been a taching bolt to the stabilizer spar resistance to oppose the movements of the (NAS 144) failure was at an average elevator tip, hence, the hinge must still load of approximately 6,700 pounds, have been attached to the stabilizer An examination of the inboard side of the whereas the ultimate rated strength is casting indicates that the ten attaching 5,100 pounds. (b) These bolts are manufactured by rivets had sheared due to torque result- an automatic machine so that the dimen- ing from down elevator sions of the indentation in the head for In logical pursuit of this theory we the insertion of the Internal wrench are ii ay conjecture that previous to this kept within close tolerances, Machin- flight the airplane was subjected to ists do not counterbore these heads. severe gusts on the ground while the (c) The margin of strength of the elevator gust lock was disengaged re- four attaching bolts of the hinge to the suiting in sufficient buffeting of the rear spar is excessive. tall to cause a whipping action on the 5. Possibly a elevator tip. Weakening of the torsion large bird hit the hori- box could have occurred at this time zontal surfaces- This must be dis- The tip would still have been attached counted as there was no evidence of to the elevator by the top skin around feathers or bird remains anywhere on or the cutout and to the hinge. The ele- in the horizontal surfaces vator on the Inboard side of the outer 6. Possibly some part of the aircraft hinge would then have almost no re- came loose and struck the horizontal straint in the vertical direction and surfaces. This theory may be discounted would move upward due to the normal loads because acting on the surface This would have (a) All doors in the fuselage, two on permitted the start of the unportlng at the left and one on the right side the this end. Meanwhile, the elevator tip nose wheel doors, the fuselage accessory would have started gyrating and it is compartment door, the two baggage doors, possible that this would have helped in all four emergency exits, all the land- the unporting process. ing gear doors in the^nacelle structure, In connection with the possibility of and all engine air intakes oil coolers tail damage by buffeting or collision to and cylinders--- in short all parts that this aircraft, Safety Bureau personnel conceivably could have fallen off---were carried out widespread and exhaustive found in the area of the main wreckage investigation. Their work included con- or were accounted for. tacting ground and maintenance personnel --- 19491 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 of the carrier and examination of their unscrewed, the result could have been no records in an attempt to ascertain if more than a gradual lengthening of a this aircraft had ever been subjected to cable with loss of tension and conse- high ground gusts with the gust lock quently it could not have had appreciable disengaged or to damage by buffeting or sudden effect upon tab motion from the slipstream of other aircraft as 9 Another possibility is that the from tail-to-tail parking, or had been elevators overbalanced. (Certain air- actually damaged in a ground collision craft with a large percentage of eleva- All results were completely negative tor aerodynamic balance have a tendency 8 Another possibility is that the to develop elevator overbalance under dive was initiated by an abrupt deflec- certain conditions ) Flight tests were tion of the elevator trim tabs occasion- made on a similar aircraft loaded under ed by a parted elevator tab control the optimum conditions of weight, speed, cable This theory was explored and al- center of gravity and maneuver to Induce so refuted Tests were run and reports overbalancing of the elevator They thereon were submitted to the Safety showed that the elevator has no tendency Bureau relative to effects of a sudden to, and did not, overbalance release of stored energy in the tab con- 10. Still another possibility is that trol system on the motion of the tab it- of the wilful and experimental engage- self These tests were conducted on the ment of the gust lock- It is interest- ground, both with and without engines ing to note that this accident occurred running and with the tab control cables less than 24 hours after a disastrous loaded to various values crash of a similar airplane at LaGuardia The possibility of the dive being Airport Due to the nature of that ac- started by such breakage was based on an cident It was commonly surmised that the assumed Initial 70-pound tension m the aircrafts gust lock was not disengaged. control cables, engines running, and on This suggests that the subject crew may the assumption that the parting was have been experimenting with the gust abrupt However, the aircraft manufac- lock in flight inasmuch as the flight turer recommends that a tension of 35 was out of Newark only about an hour and pounds be rigged in these controls, 76 it is most probable that the whole mat- similar aircraft were checked and it was ter of gust lock engagement would have found that the average tension of those been of great concern to the flight crew 76 was 32 pounds with no marked devia- (In connection with the LaGuardia crash, tions therefrom Also the values in the the Board found that the gust lock had report used a factor of 1 1/2 to account not been disengaged ) for the effect of engines runnIng whereas Coincidental to this theory, an acci- values were already listed for the effect dent occurred approximately four months with engines running at an initial ten- later when a similar aircraft had its sion of 35 pounds. Hence, the values as gust lock intentionally engaged m flight listed in the report for the tab deflec- near El Paso, Texas. That aircraft sub- tion were excessive by a factor of three. sequently maneuvered remarkably like the The values for tab jump corrected for subject aircraft. At Bainbridge the this factor are such that it could not aircraft was cruising at about 4,000 cause the uncontrollability of the air- feet above the ground when it entered plane and almost completed the first half of Tests were made to determine the ef- an outside loop before striking the fect on control cable tension when the ground. At El Paso the aircraft was cable was cut gradually, strand by cruising at 8,000 feet or about 4,000 strand It was found that the Initial feet above the ground That aircraft tension diminished rapidly as more and executed and completed the first half of more strands were cut This test on the an outside loop but with only about 300- gradual parting of the cable was made 400 feet to spare. That the Bainbridge because it is inconceivable that such a aircraft did not clear the ground whereas cable could part in any other manner. the El Paso aircraft did may be accounted This gradual parting and ensuing release for by the fact that the Bainbridge air- of tension would result In a small and craft was under continual power while gradual movement of the tab dependent the El Paso aircraft had three of its upon an Inconsequential lengthening of propellers feathered inadvertently the cable. Even if a turnbuckle had This difference in propulsion could readily account for the difference In empennage and/or its controls was an ef- radii of the two outside loops fect or a cause of the dive is not known This theory, however, seems quite un- likely in view of the Captains back- Probable Cause ground He had been an able test pilot The Board determines that the prob- of large aircraft and as such would have able cause of this accident was a sudden been fully aware of the possible results loss of control, for reasons unknown, of such experimentation To experiment resulting a dive to the ground m this way would, have beer completely contrary to established sound operating Corrective Action procedures incumbent upon air-line cap- tains As the result of the investigation of These ten tneones represent the this accident, the Civil Aeronautics Ad- seemingly outstanding ones and so have ministration issued two Airworthiness been discussed As will be noted most i irec tives These are of them are obviously refuted while 1, Issued during the ^7th week of others are left as unproved and unprov- 1947, and to be effective not later than able The last, of course, is pure July 15, 1947. Unless already accom- speculation based upon conceivable crew plished and at periods not to exceed behavior It is a theory neither sanc- 1 JOO hours flight time, or, In the case tioned nor refuted but offered for what of Scheduled Air Carrier Operations, in it is, a seemingly possible answer. multiples of major Inspection closest to The entire investigation has probably 1,000 hours, the following must be ac- been the most intensive in the history complished of the Boards Safety Bureau and its (a) Remove and inspect all hinge bolts predecessor organizations From it the through bearings at elevator and rudder entire vital subject of air safety has hinge and inspect bearings for proper in- received great benefit Board personnel stallation and operation delved deeply and exhaustively into all (b) Remove and inspect all bolts maintenance matters that were even re- through elevator and rudder tab ninge motely suspected as having been the bearings and inspect bearings for proper source of failure in the subject air- installation and operation craft and into other maintenance matters (c) Check bearing eyebolt nuts for quite removed, at least on the surface, proper torque at all iudder and elevator from the probable initial failure in hinge stations this case A result of this stringent (d) Check rudder and elevator hinge Inspection has been an admittedly bene- bracket attach bolts at stabilizer rear ficial overall tightening of air carrier spar for proper torque, and on first in- maintenance procedures spection check bolt length and thread en- Findings gagement (e) Check elevator and rudder tab Upon the basis of all available evi- brackets for proper installation includ- dence, the Board finds that ing hinge alignment 1. The aircraft, crew and carrier (f) Proper torque values for all were properly certificated points to be checked are given in DC-4 2 There was no malfunctioning of any maintenance manual It is important jn uower unit checking torque that part be loosened and 3 Weather was not contributory and then retightened to proper torque Do the air was smooth not tighten above recommended, torque value, 4 The flight was routine until it (g) Remove the paint from the follow- neaped Bainbridge, Maryland ing hinge brackets and inspect for cor- 5 An uncontrolled dive started from rosion and any evidence of cracks Rud- the planned cruising altitude of 4,000 der hinges, rudder tab hinges, elevator feet hinges, elevator tab hinges. 6. Ine empennage disintegrated during Hhen any defects are found, the defec- the dive but whether failure of the tive parts must be replaced Immediately with Identical new parts installed (4) Line ream hole 3120- 3140 In accordance with the methods and bolt inches in diameter through bush- torque values applicable, as shown in ings after pressing into hinge the Douglas DC-4 Maintenance Manual Vol- fitting. ume VI, pages 323 to 331, inclusive. (5) Remove outboard elevator hinge 2 Issued during the 33rd week of eyebolt assembly, P/N 2110992, and install new assembly, P/N 1947, and to be effective not later than 2328991. October 15, 1947. The following is to (6) Re-install elevators using be accomplished to reduce the possibi- 2357035-15 bolt through bushed lity of wear of the outboard elevator hinge bracket and new eyebolt as- hinge parts Inspect immediately for sembly, with 1357162 washer (two wear, proper installation and operation required---one under head of bolt unless already accomplished, and at pe- and one under nut). ANS10-5 nut riods thereafter not to exceed 250 hours and AN 3 80-2-2 cotter pin. flight time, or in the case of Scheduled (b) The horizontal stabilizer outer Air Carrier Operations, at each major hinge bracket, P/N 5109899, was replaced inspection closest to 250 hours until in later production aircraft and on some the following mandatory rework is accom- aircraft in the field with P/N 3323406. plished. This latter bracket incorporates a 5/16- (a) Each horizontal stabilizer outer Inch bolt with eyebolt P/N 2328991, and hinge bracket, P/N 5109899, must be re- must be reworked In accordance with worked as follows parts 1,2,3,4, and 6 of paragraph (a) (1) Line Ream .3745-.3755-inch- above. (Douglas Service Bulletin DC-4, diameter holes through the two #73 dated September 23, 1947, covers lugs at each hinge point. this same subject. An earlier issue of (2) Press in 3323406-A-2 Bushings, this Service Bulletin dated June 12, 2 req., made from 9/16-inch- 1947, called for NAS 55-15 bolts in dlameter Corrosion Resistant paragraph (a) (6), above. It is satis- Steel Bar, Spec Am.QQ-S-771, Comp. factory to leave the NAS 55-15 bolts in- FM, Cond B., or bushing, P/N stalled on airplanes reworked as per the 1356866, which may be purchased original Issue of the Service Bulletin.) from the airplane manufacturer (3) Machine shoulders of bushings 01 THE CIVIL AERONAUTICS BOARD on inside of lugs to obtain Is/ JOSEPH J O'CONNELL, JR clearance for bearing in eyebolt of .563 inch, plus .005 inch and 1 sf OSWALD RYAN minus .001 inch Minimum thick- fsf JOSH LEE ness of shoulder on each bushing / s/ HAROLD A JONES after machining should not be less than .020 Inches Adams, Member, did not participate --- 19491 Supplemental Data Investigation and Hear in 4 at the time of the accident had piloted The Civil Aeronautics Board was noti- a total of 2,550 hours Including about fied of the accident immediately by 488 hours in DC-4s or the military Safety Bureau personnel who witnessed it equivalent. The aircraft carried two An Investigation was initiated at once cabin attendants Theodore Lundstrom m accordance with the provisions of and Helen Elizabeth OBriep. Section 702 (a) (2) of the Civil Aero- Aircraft nautics Act of 19383 as amended. The aircraft wreckage was placed under guard shortly after the accident and guard was This aircraft, a Douglas Model C-54- maintained until the wreckage had been R, serial number 18380, Army identifica- completely inspected and released by the tion number 43-17180, was manufactured Safety Bureau. In connection with the by the Douglas Aircraft Company of Santa Investigation a public hearing was Monica, California, in November 1944, ordered and held, in three sessions, at for the United States Army Air Forces. Bainbridge, Maryland, on June 16, 1947, On November 15, 1945, it was declared at New York, New York, on July 17, IS, surplus by the Air Forces and title was 19, 1947, and at Washington, D. C., on transferred to the War Assets Adminis- April 30, 1948. tration. Eastern acquired the aircraft on November 29, 1945, under a lease Air Carrier arrangement title remaining with War Assets Administration. Subsequently, Eastern Air Lines, Inc., a Delaware the Martin Aircraft Company of Baltimore, Corporation with headquarters in New Maryland, modified it for civil use. At York City, was operating under a certif- the time of the accident it had been icate of public convenience and neces- operated a total of 3,623 hours, of sity and an air carrier operating cer- which 877 hours had been In the military tificate, both issued under authority of service, and maintenance records relative the Civil Aeronautics Act of 1938, as to the aircraft and its four powerplants amended. These certificates authorized Indicated adherence to all prescribed the company to fly persons, property and periodic inspections and replacements. mail between specified points in the The most significant item in the history United States including Newark New of the aircraft is that it was landed Jersey, and Miami, Florida. wheels up on or about February 21, 1945, while in use in the Service. The re- Flight Personnel sulting damage was adequately repaired William Evitt Coney, age 41 of Coral according to records. Gables, Florida, was captain of the air- Upon departure from Newark on the craft. Be held a valid airline trans- subject flight the aircraft was loaded port pilot rating and at the time of the to a gross weight of 07,968 pounds, accident had piloted a total of 11,514 approximately 4,000 pounds less than the hours including about 633 hours in allowable gross take-off weight of Douglas DC-4s or the military equivalent 71,750 pounds, and its center of gravity (C-54) . K. V. Willingham, of Coral was within prescribed limits. The air- Gables, Florida, was copilot. He held a craft was not equipped with an automatic valid airline transport pilot rating and pilot. -19491 (I) I NAW WRECKAGE / Mormwu rsWfSTto am* MflLRfc 1 ----' - 5 U.S N.T.C^ OAtNfrmptf Mp. PVRWESI APHRO KMAYecY i > MILES 13* V Mt$powr HU DtNJFL'l fftRtSTEP WLA r^nc.e LEGEND MAGNE TO BtARiNfc M75* SA S w OUTER tet-T HAHD ElSVaTOR RUDPCR TAB' RMODER T1& . General 5ite Plan INNtR LEFT HAND ELEVATOR LEFT WAND STAB IDLER . Tai? Assembly vAIrlcRagl scAte.i- ipo CENTER ELEVATCff HINGE . LOCATION RIGHT HAND 5 TABLIZ ER. SPAR , LAHlTUDL 39 ?T'H t RlGrMT HAND t LEVATOR . LON^nuot 76* 3 W 5 i RlOHT HA**P STABUZtR . reiMT r*o 5 GF T*>l Aw***lt stabilizer TiF* STABILIZER TIP. i RIGHT HAND 5? 3gtc> <*> c& I *> 33 - r i ___1 S?CO ____I ! J.O6 r 4 L ___+1 3$oo ^ .zm -mo t 3^06 1 1 NOTE 33BO _____1________ iieuAYiwe locations parts Profile of Gfucral Site Plan TAKEN FROM FltUO SKETCH . 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H PHUB , 1 1 j 1 1 DATA WAMHD IW FtELD V SURVEY PARTY OH>OUlWiMT . 1 1 MAIM WKKMAGE AREA PMJCTBO FT UM OP PLAH6 TABU MR 8 ALrMBe.tt STAO4A BOAMB . | I 1_________J GCNVRAU VtE PLAN PLOTTEO S* 350G a a a a a 1 " ' ROMHIMG AM OPE* TRMM&E W WITH TFM-WTOl MX' SHM-TAPE * V a a Z a * V a a a 34M L-------- aa Z . at \_______r . * * j i . . , 1 a a 3300 ____________ ., ' * ADDENDA KOTfi : ..HM- Z4 50 40 1L. ME eV SAFETY BUKBAo H1T |G- ALL POSITION * A. .13 7^49 IHCL. AS C4TIMAT* .BUT AW HRU44tTFL SCALt !* 10 /reckage Distribution _ CGWA3CY WLAYlVELY t Ve*?tcAi Scale <*<10 XE. AJ0K FOTTIOM VeRTfCAL SiAaHlXCA . 3a LEFT tlOE OP <4AR CABtM r . Of PART OF FSM CtUM - ' 35 RIAHT CCWT6R SECTION REAR UPPER SPAR CRASH OF EAL-C 54B DC - NC666H . XG TSP S1CT1OM DF RUW> 34 PWETJOW OF FLOOR STRUCTURE . (708 HC MS14A . 3 MCT OP LBFT VON ft Hear 0AtNBRipE.Mo. O* May 30J947 AT . L0WKW TMtC. SECTION C FUSEMlGft . 3* AILBRON L . iUROARO . ^--- WV ---XO.U ........... aj LOWE* PSWTIOK > Kiii , 37 *CTi*4 OF LfiFT WIK6. rr Km Cnrrt. Ae>MjHirk.& X*V SBCTIOM OF T*1U Cttia. 75 1HBOARP BNO AUEHftN St CTf ON OF L>W*6- RW. *. : .- :' * : :: . i:,;:: r.-. 3* ROmM TORAOE TUM ELEVATOR 33 LBFT 4IWG UOVUft 7AHK IA%f>CCTW* PLATE . 9! 2 amNjwiKrtMk.- Ha-wA*' 31 TAtL W 4ECT|6fl~ 40 Ltrr v '. W-. JfcWfc 04T- J$AciX-A> Imomctc^ i ***** w * a . . : ... .. . . z ..?. *L*2S'-S *----* . CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted September 22, 1950 Released1 September 26, 1950 EASTERN AIR LINES, INC. AND R-38 AIR COLL ISI ON ---NEAR WASHINGTON NATIONAL AIRPORT, WASHINGTON, D. C., NOVEMBER I, 19*49 THE ACCIDENT Rios m conmunication Departure of the Eastern Air Lines' Flight 537, a DC-4, P-38 was noted by the tower to be at 11 37, N-88727, and a P-38 aircraft bearing identi- and from that time until after the accident, fication NX-26927 collided at approximately visibility m the vicinity of the airport 11 46,1 November 1, 1949, while both planes remained at 15 miles, ceiling was 6,500 feet were on final approach for landing at the with scattered clouds at 3,500, and surface Washington National Airport, Washington, D C wind was from the northeast 20 to 25 miles All of the 51 passengers, including two per hour babies m arms, and the flight crew of four Testimony of control tower personnel and m the DC-4 were killed, the pilot of the that of the pilot of the P-38 were in con- P-38 was seriously injured Both aircraft flict Rios stated that he had taken off not were completely destroyed from Runway 3, but from Runway 36, turning left at an altitude of about 300 feet His HISTORY OF THE FLIGHTS climb was made, he said, to the north of the On November 1, 1949, Eastern's Flight 537 Pentagon, and because of the erratic opera- was flying from Boston via intermediate tion of the right engine, he decided to land points to Washington Over Beltsville, 15 as soon as possible Continuing to climb to miles northeast of the Washington National about 2,500 feet or more, he made a second airport, it contacted the Washington Control left turn so as to fly south, parallel to Tower on 119 1 megacycles voice communica- Runway 36, and when abeam of the control tions and was cleared by the tower to enter tower, he transmitted, Washington Tower, a left traffic pattern for landing on Runway this is Bolivian P-38 I got engine trouble- 3 One minute before, at 11 37, the P-3 request landing instructions His testimony flown by Erick Rios Bridoux, a Bolivian continues to the effect that because no national, had taken off from Runway 3 at answer was received, he turned left again to Washington National Airport circle the field where he could see light Rios was test flying the P-38 for accept- signals from the tower He stated that he ance by the Bolivian Government Previously, received none, but that when he was between he had notified the tower through Paul M Bolling Field and the National Airport and Aubin, that he intended to make the flight at about 3,500 feet altitude, the tower and that his communications with the tower asked, Bolivian P-38, you were asking land- would be accomplished over VHF radio, Channel ing instructions? Rios stated that he B on 126 18 megacycles Rios also stated answered, Yes, I have engine trouble I am that he requested Aubin to notify the tower in a hurry," and that the tower at that time to give him a light if radio contact could responded, Bolivian P-38 cleared to land not be established This message was not number two on Runway 3 Rios stated that transmitted to the tower and Aubin denied the tower did not inform him that the air- hearing Rios make this last request Through- craft ahead of him was an Eastern DC-4 Rios out the entire ground operation of the P-38, said that he continued to turn left, and at including clearance for take-off, no diffi- a reduced speed of 150 miles per hour, culty was experienced by either the tower or started a descent of 500 to 600 feet per min ute, completing a second 360-degree turn ^All tunes referred to herein are Eastern Stand- around the airport until reaching an altitude ard and based on the 24-hour clock of approximately 2,400 feet Rios said that a downwind leg was flown at high final approach The controller there- about 1,500 feet, and when about five miles upon requested Rios to make a 360-degree south of the field, he turned left 90 degrees, turn to his left, saying that he was number flying east on a short base leg at an alti- two to land following an Eastern DC-4 turn- tude of about 1,200 feet During his down- ing on its final approach below Since wind leg, he observed a C-60 or C-45 on there was neither acknowledgment nor com- approach to Runway 3 or 36, and while on his pliance with this second instruction, another base leg, he saw it complete its landing and transmission was made to the P-38, which was turn off the runway to the left Rios made identified as Bolivian 927, and Rios was a left turn from the base leg to an approach then told Turn left, turn left," and was course of 20 degrees for landing on Runway 3 again told that the DC-4 was turning on final As soon as the turn had been completed, Rios approach below Again there was no response transmitted, Washington Tower, this is or compliance by the P-38, whereupon the Bolivian P-38 on approach The tower re- tower then instructed the Eastern DC-4 to sponded, said Rios, Bolivian P-38 cleared turn left The DC-4 promptly acted m re- to land on Runway 3 Rios stated that his sponse to this instruction, but before 5 approach was made a little higher than nor- degrees of turn were made, the two aircraft mal, for safety reasons, and that one minute collided at an approximate altitude of 300 after leaving the base leg, he extended the feet about 1/2 mile southwest of Runway 3 flaps, the landing gear having been put down In addition to the foregoing, there were previously when he was west of the field two additional sources of information as to Rios heard the tower say, Clear to the left, the communications between the tower and the clear to the left, but he stated that he did two planes involved in the collision not know for whom it was intended because the National Airlines' Flight 53, a DC-4 fly- tower did not use any call sign Almost im- ing the same route as the Eastern flight, mediately afterwards, he felt the shock of received when over Beltsville at approxi- the collision with the DC-4 mately 11 41 a clearance from the Washington According to control tower personnel, the National Control Tower to enter the traffic P-38 took off from Runway 3, turned left, and pattern The copilot of this flight stated proceeded in a climb 10 miles west of the that irranediately before, he had overheard field Then a second left turn was made, and the Washington tower give the Eastern flight the aircraft, still climbing, continued m a a clearance to enter the traffic pattern southerly direction The P-38 was next ob- At about 11 44, three minutes after the served from the control tower circling left, National plane had received its clearance to south of Alexandria at an estimated altitude enter the traffic pattern (Eastern1s DC-4 between 3,000 and 4,000 feet The tower was at this time north of the airport m the operators stated that while the P-38 was traffic pattern on its downwind leg), the circling south of Alexandria, they received, National copilot heard the tower tell the tl Washington Tower, this is Bolivian 927 re- Eastern crew that there was a P-38 in traf- questing landing instruction " After the fic The National copilot further stated controller had asked if Bolivian 927 had re- that about two minutes after this transmis- quested landing instructions, and the pilot sion to the Eastern flight, he overheard the had replied affirmatively, the controller tower tell the Eastern flight m a rather instructed the P-38 to enter a left traffic alarmed voice, Look out for the P-38 pattern for Runway 3 and to report when west (Eastern at this time had just coupleted its of the tower on downwind leg When the in- turn onto final) He did not recall hearing struction was not acknowledged by Rios, it a request for landing instruction or the was repeated Prior to these instructions, tower giving landing instructions to the the tower had cleared the Eastern flight to Eastern crew The captain in the National land number one on Runway 3 DC-4 had no recollection of these transmis Shortly after the Eastern DC-4 was ob- sions described by the copilot served 1 1/2 miles west to southwest from the Sgt William S Buckwaiter, who was serv end of Runway 3, making a continuous left mg as a controller in the Bolling Field turn from the downwind leg to final approach, tower, which had a speaker tuned to Channel tower personnel observed the P-38 on a long B, testified that he heard an alarmed voice ---15354 saying, Bolivian, Bolivian, Bolivian, and The evidence shows that the traffic around looked up just in time to see the crash He the Washington National Airport was light also remembered having previously heard rou- during the critical period, 11 37 to 11 46, tine landing instructions transmitted to the and the only aircraft other than the P-38 P-38, but did not recall hearing any acknowl- and Eastern's Flight 537 which could have edgments of such instructions constituted landing traffic was a United States Air Force B-25 which made a practice RECONSTRUCTION OF EVENTS instrument approach to Runway 36 This air- From the testimony summarized above and craft, however, according to the landing from all other evidence which was received records, passed over the field without land- during the course of the investigation and ing at 11 43, about three minutes before the hearing, the following events and their se- accident quence appear to be supported by the prepon- A careful scrutiny of the tower's records derance of evidence (which record every aircraft take-off and Following take-off, Rios climbed straight landing at National Airport) fails to reveal ahead to approximately 300 feet, then turned any C-45, C-60, or similar aircraft which left and continued to climb on a westerly landed during the period of the flight of the heading In the turn, engine speed and mani- P-38 Neither the tower personnel, the rep- fold pressure of the right engine became er- resentatives of the Bolivian Government who ratic, so Rios decided to land as soon as were watching the flight, nor other eye wit- possible Rios, however, did not believe nesses were able to recall seeing such an this erratic operation of the right engine aircraft land was serious enough to warrant any emergency At approximately 11 44, Eastern's Flight action He attained an altitude of 3,500 537 was cleared to land number one on Runway feet on the westerly heading, leveled off, 3 This clearance was given when Eastern turned left for a second time, and then flew was on its downwind leg west of the field south The weight of the evidence irtdicates Eastern made a continuous turn from its down- that Rios was confused as to his location and wind leg west of of the field to a final that the tower personnel were correct m approach to Runway 3 During this turn, the their statements that the P-38 was circling P-38 was south of the end of Runway 3 on a at a high altitude about 5 miles south of high straight-in approach for landing on the National Airport Rios was unable to iden- same runway on which Eastern had been cleared tify any landmarks south of the airport and to land---runway 3 stated that this (i e , navigation by land- Following the DC-4s clearance to land, marks) is not my way to fly I do not take instructions were given to Rios to enter left care of the small details on the ground traffic pattern and to call the tower when W T Snead, a witness with considerable ex- west of the field These instructions, al- perience in aviation,2 observed from the though repeated by the tower, were neither Hybla Valley Airport, near Alexandria, a P-38 acknowledged nor complied with Instead, the flying with its landing gear up at about P-38 started a straight-in approach on an 3,000 or 4,000 feet in the vicinity of Alex- approximate heading of 20 degrees Rios was andria Thus, the weight of the evidence in- then requested to make a 360-degree turn to dicates that Rios circled at a high altitude the left and to land number two following about 5 miles south of the airport and made a the Eastern EC-4 turning on final approach long, high final approach toward Runway 3 A below him direct approach from this location and altitude As the Eastern DC-4 rolled out of its would, of course, require a rapid rate of de- left turn onto final approach, approximately scent in order to reach the end of Runway 3 3/4 mile from the end of Runway 3, and as the P-38 continued to descend above and be- hind the DC-4, the tower transmitted to Rios Snead is a flight instructor at the Hybla Vai- either, Turn left, turn left, or Clear ley Airport --- 15354 to the left, clear to the left Since the and required an S-turn on final approach for P-38 still did not comply, and a collision landing on Runway 3, it was not consistently now appeared imminent, the tower switched to followed A general practice, which became I the DC-4 frequency^ and instructed the coiunon usage, was to turn to final approach Eastern crew to turn left because a P-38 was for Runway 3 from a downwind leg which was on the approach behind them The Eastern flown relatively close to the airport It flight responded imnediately by applying was the general undeistanding among pilots power, leveling off, and turning left But, and tower personnel that permission from the before more than 5 degrees of turn were made, tower to turn to final approach was implied the two aircraft collided at a point m line by the towers clearance to land number one, with and 1/2 mile from the approach end of that is, that "clear to land number one Runway 3 at an altitude of 300 feet meant "clear to turn to final approach and 1 and TRAFFIC PATTERN AT WASHINGTON NATIONAL AIR PORT ANALYSIS A full understanding of the facts sur- Conceivably, a good part of the towers rounding this accident requires consideration instructions to the P-38 may not have been of the traffic pattern which was m effect at received If Rios had been calling the the Washington National Airport at the time tower at the same time the tower was attenpt- of the accident This pattern which had been ing to give him instructions, neither the originally designed to provide an orderly tower nor Rios would have received the in- flow of traffic was modified to reduce noise tended messages, since the transmission and over the congested area around the airport reception on any one particular radio fre- The pattern as approved and published by the quency cannot be effected simultaneously Administrator5 recruired an aircraft when However that may be, a landing approach approaching from the northeast for landing on should not have been initiated until clear- Runway 3 to fly west until west of the Pen- ance to land was received Although Rios tagon, then south so as to pass south of the stated that he had been given a clearance to City of Alexandria, then north over the land, the preponderance of testimony indi- Potomac River, turning left so as to arrive cates he was given clearance to enter traf- over the Potomac Railroad Yards from where a fic pattern only The first clearance to right turn could be made to line up with Run- Rios was to enter a left traffic pattern and way 3 The flight path, as described, was the later clearance, not given until after a to be flown at a minimum altitude of 1,200 landing approach was started, was to land feet until the aircraft arrived over the number two behind an Eastern DC-4 He was Potomac River never given a clearance to land number one Investigation disclosed that because the It is also possible that Rios, when he Washington traffic pattern was long, involved, was told to enter the left traffic pattern It is impossible to determine which of these and later to land number two following the warnings was given, (or whether the call sign Bo- Eastern DC-4, believed that the B-25 which livian 927 was used) due to the lack of corrobor- had made a simulated instrument approach to ating evidence There were no recordings of any Runway 36 was the number one aircraft that of the conversations with the P-38 because they were- made from the 'A" position (Local Control Position) had been referred to by the tower However, The CAA did not have sufficient funds to record Rios insisted that he saw the number one air- all positions, and priority was given to the C r* craft land and taxi off the runway to the position (Approach Control Position) and the radar left whereas the B-25 passed over the runway position (Ground Control Approach Position) vlhis policy was established during the Summer of 1949, without landing Moreover, Rios stated that several months before the collision he did not see a B-25 but a C-45 or C-60 and 4 The P-38 was on a frequency of 126 18 mega- that because of his Air Force training m cycles, while Eastern was on a frequency of 119 1 megacycles, and, consequently, neither plane could aircraft recognition, it would be difficult hear the transmissions between the tower and the for him to be confused on this point The other plane However, simultaneous transmissions evidence clearly indicates that no C-45 or could have been made on both frequencies if the operator had simply held two frequency toggle C-60 landed at that time switches lt on instead of one Even assuming that Rios was confused as See Appendix I to which aircraft was number one, the fact -1 C'Z remains that a clearance to land number one they failed to observe the P-38 And if the was not given to Rios Weather at the time crew of the DC-4 had observed the P-38, they was clear, and the DC-4 could have been ob- could not reasonably have been expected to served with the exercise of reasonable care conclude that the P-38 constituted conflict- even if Rios had not received the advisory ing traffic m relation to the DC-4 information from the tower to the effect It remains to be determined whether those that Eastern was on base leg ahead of and be- in the control tower discharged their duties low him For although visibility from the as prescribed by Civil Air Regulations and cockpit of the P-38 was limited in a forward by the Administrators rules The Civil Air and downward direction, the aircraft could Regulations require all flights to conform readily have been maneuvered so that any air- with air traffic control instructions6 and craft ahead could have been seen Since Rios the Administrators rules, which supplement was making a long, high final approach, he the regulations, provide that an airport should have maneuvered the P-38 so that he traffic controller shall issue clearances and could make sure that there were no aircraft other information which may be necessary for in front of him Even accepting Rios' state- the prevention of collision 7 Duties of the ment that he flew a downwind leg, a base leg, and control tower personnel, therefore, include then made a final approach which was only a few alertness for the presence of all aircraft hundred feet higher than a normal approach, in a traffic pattern and advice to pilots the fact remains that he could easily have engaged in landing aircraft of the presence seen the DC-4 while he was on his base leg and position of other aircraft which might and should have kept track of its position constitute a collision hazard Accordingly, it must be concluded that the According to the testimony of the tower landing approach of the P-38 was made not operators, the P-38 started its straight- only without assurance from the tower that m approach five miles or more from the end there was no conflicting traffic, but also of the runway 8 At an air speed of 150 mph. without the exercise of the vigilance required which Rios testified he had, it would require in initiating and pursuing his long, very approximately 1 3/4 minutes for him to fly steep straight-in final approach As a re- to the point of the collision During this sult, the P-38 overtook and struck the DC-4 time, the flaps and gear of the P-38 were The full examination of the facts and cir- extended, and the airplane descended rapidly cumstances of this accident cannot, however, as it flew toward the end of Runway 3 terminate with the conclusion as to the re- Eastern, having been given a clearance to sponsibility of Rios Consideration must land number one, actually was turning from also be given to the actions of the Eastern its downwind leg to final approach When the crew and the control tower Insofar as P-38 did not conply with the Turn left, Easterns flight is concerned, it had a turn left, or Clear to the left, clear to clearance to land number one which, as pre- the left, radio conHnuni cat ions, the tower viously explained, is commonly understood by then warned Eastern Two other alternative the tower and airline crews serving Washing- or additional courses of action were avail- ton as a clearance to turn to a final approach, able to the tower xn an effort to persuade and as an indication from the tower that the Rios to discontinue his approach or otherwise approach path is clear The crew of the DC-4, to avoid the disaster The first was the use therefore, could reasonably have expected to of the red light after Rios failed to ac- be able to complete their approach and land- knowledge or comply with the second instruc- ing without interference from other aircraft tion from the tower to make a holding turn Although the Eastern crew had a duty to main- tain a reasonable lookout under all the cir- 6Civil Air Regulations 60 19 Air Traffic control cumstances, m view of the fact that during instructions "No person shall operate an aircraft contrary to air traffic control instructions m the critical period they were engaged m areas where air traffic control is exercised turning from downwind leg to final approach, 7 Section 26 26-65 (Administrators Rules) An and that they were engrossed m the task of airport traffic controller shall issue such traffic landing, for which they had been cleared, the clearances and other information as are necessary for the prevention of collisions between aircraft crew did not act m a manner inconsistent under his jurisdiction with such duty if under these circumstances ^Transcript of Testimony, pp 98, 182 The second was the earlier use of the radio any authorization been given by the United to warn Eastern An accurate appraisal of States Government for its flight of Novem- whether either or both of these courses of ber 1 action should have been employed or would 3 No difficulty was experienced in the have averted the disaster requires the as- operation of the Eastern Air Lines* DC-4 or sessment of facts with a precision not pos- any of its corrponents, including the radio sible from the record 4 Other than the erratic engine speed The use of the red light might have al- and manifold pressure of the right engine of tered Rios course and avoided the accident the P-38, there was no mechanical trouble On the other hand it might have confused the experienced m its operation crew of Eastern, as the tower feared it 5 Visibility in the vicinity of the would, and hastened the accident Rios might Washington National Airport at the time of not have seen the light, or having seen it the accident was 15 miles, ceiling was 6,500 disregarded it feet, and surface wind was from the northeast Eastern might have received an earlier in- at 20 to 25 miles per hour struction to alter its course The accident 6 Approximately two minutes before the might have thus been avoided On the other collision, Eastern Air Lines* DC-4 was on hand, Rios rapid pursuit of his conduct to downwind leg, at which time it was cleared to the point of apparent collision left only land number one on Runway 3 seconds available for observation and deci- 7 The P-38 was 2 1/2 to 3 miles south of sion lhe tower relied upon radio contact the end of Runway 3 on a high straight-in with Rios and the control of his actions approach to that runway when the tower ob- Such contact had been established only a mat- served the Eastern flight m a continuous ter of one or two minutes before, the re- turn from the downwind leg to the final ap- sponse had been slow but there was reception proach about 1 1/2 miles west co southwest of It can not be said With certainty whether the the approach end of Runway 3 moment when this course of action should have 8 The pilot of the P-38 attempted to been abandoned became apparent m sufficient land the airplane without obtaining the re- time to make another course of action effec- quired clearance from the tower, and without tive maintaining a proper lookout for other air- We impute poor judgment to the tower m craft its adherence to the single course of guiding 9 The P-38 and the Eastern DC-4 collided and corrective action which it selected even at a point in. line with and 1/2 mile from though normally it had every right to expect the approach end of Runway 3 at an altitude such action to be effective Full alertness of 300 feet and dispatch on the part of personnel trained 10 The tower did not act with the requi- to anticipate and cope with critical traffic site alertness and promptness m communicat- situations called for an earlier effort to ing to Eastern the position of the P-38 in notify Easterns pilot of the position and the critical traffic situation which con- course of the P-38 in an additional effort to fronted it, but this cannot be said to have avoid the collision We can not, however, contributed to the cause of the accident under all the circumstances and particularly Rios unpredictable actions, assert that a PROBABLE CAUSE different or additional course of action by The Board determines that the probable the tower m the time available to it to rea- cause of this accident was the execution of a sonably select such action, would have straight-in final approach by the P~38 pilot averted the accident without obtaining proper clearance to land and without exercising necessary vigilance FINDINGS 1 Eastern Airlines, its crew, and its BY THE CIVIL AERCNAUTICS BOARD aircraft were properly certificated 2 Erick Rios Bndoux held a valid lim- /s/ OSWALD RYAN ited pilot certificate issued by the Adminis- /s/ JOSH LEE trator of Civil Aeronautics, but the aircraft /s/ HAROLD A JONES which he flew was not certificated, nor had /s/ RUSSELL B ADAMS Supplemental Data INVESTIGATION AND HEARING and from 1942 through 1945, he received addi- The Civil Aeronautics Board was notified tional flight training with the U S Air of this accident at 11 57 EST, November 1, Forces In addition to the above, Mr Bios 1949, by telephone from the Washington Na- received instructional training with a U S tional Airport An investigation was immedi- air carrier and with the CAA Mr Rios was ately initiated m accordance with the provi- issued a limited pilot certificate by the CAA sions of section 702(a)(2) of the Civil Aero- July 30, 1947 At one time, Rios failed an nautics Act of 1938, as amended A public examination for an airline transport pilot hearing was ordered by the Board and was held certificate However, such a certificate was in Washington, D C , November 9, 10, 11, 12, not necessary to fly a P-38 because a limited and 14, 1949 After the hearing, the Board pilot certificate permitted Rios to pilot continued its investigation by gathering ad- multi-engine aircraft except that passengers ditional evidence and by taking depositions and goods could not be carried for hire Be- of additional witnesses fore Mr Rios had been granted the limited pilot certificate, he passed an oral examina- AIR CARRIER tion on the contents of the portion of the Eastern Air Lines, Inc , is a Delaware Civil .Air Regulations pertaining to air traf- corporation and operates as an air carrier fic rules This oral examination also showed under a certificate of convenience and neces- that Rios had the ability to speak and under- sity and an air carrier operating certificate stand the English language The information issued pursuant to the Civil Aeronautics Act for his application showed that he had a to- of 1938, as amended These certificates au- tai of 3,600 flight hours, and he had re- thorized Eastern Air Lines to engage m air ported a total of 80 hours in P-38-type air- transportation with respect to persons and craft property between various points m the United States, including Washington National Air- - THE AIRCRAFT port, Washington, D C N-88727 was a currently certificated DC-4 aircraft model C54B-DC It had a total of FLIGHT PERSONNEL 12,161 hours of flight time An examination Captain George Ray, age 33, was employed of all Eastern Air Lines maintenance records by Eastern Air Lines December 27, 1937, as a pertaining to N-88727 indicates that the air- mechanic and was employed July 1, 1939, as a craft was m an airworthy condition until the pilot He received basic training during the time of the accident No mechanical discrep- years of 1934, 1935, 1936, and 1937 Mr Ray ancies of any nature had been reported for was promoted to captain on October 6, 1941 the flight from Boston to New York, and none He held a valid airline transport pilot rat- are known to have occurred during the flight ing Certificate No 32731 His last CAA to Washington physical examination was successfully passed The P-38 had been delivered to the Army May 16, 1949 Captain Ray had a total of Air Force on April 13, 1945, by the manufac- 9,033 flying hours, of which 888 hours were turer, Lockheed Aircraft Corporation, and in DC-4 type equipment shortly after, it was declared war surplus Pilot Charles R Hazelwood, age 28, was At that time, it had a total of 15 hours employed by Eastern Air Lines as a pilot flight time The aircraft was transferred to March 22, 1946 He had received his basic the Reconstruction Finance Corporation Janu- training with the U S Air Forces Mr ary 4, 1946, and stored at Walnut Ridge, Arkan- Hazelwood had successfully passed his last sas, Army Air Forces Base The aircraft was CAA physical examination February 8, 1949 flown to Seymour, Indiana, m 1946, where it re- He held a valid commercial pilot Certificate mained until the first of October, 1949, when No 267897 Of his total flying hours of purchased by Universal Air Marine and Supply 4,396, 26 hours were in DC-4 type equipment Company for the Bolivian Government The owner- Erick Rios Bndoux, the pilot of the P-38, ship of the P-38 is the subject of a legal dis- was a citizen of Bolivia but had a good com- pute The Board takes no position on this ques- mand of the English language His flight tion because it is not pertinent to the Boards in- training started m 1938 in his own country, vestigation of the probable cause of the accident ^Obtained from RareAviation.com. 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Copyright (c) 2Oo4I:i II Supplemental Data Complete records were not available for been found other than the erratic operation the P-38, the only ones being found consist- of the right engine, which Mr Rios de- ing of Army forms, CAA registration certifi- scribed cates, two periodic inspection reports, and a ferry permit These records show that the INVESTIGATION OF THE WRECKAGE aircraft had been built for the military Examination of the DC-4 fuselage showed services, had been declared surplus, and had that it had been cut by the left propeller of been sold by the War Assets Corporation the P-38 at station 524, which is just for- Later, it was given an NX certificate for ward of the trailing edge of the wing This participation in the National Air Races On cut extended on 1 th sides of the fusel age October 3, 1949, a second periodic inspection from the top down to the emergency escape was performed on the aircraft for the issu- hatches From the emergency escape hatches ance of a ferry permit for a flight from Sey- for the remainder of the way around the fuse- mour, Indiana, to Schrom Field, Maryland lage, the structure had been torn in two None of the above certificates or periodic The aft portion of the aircraft, from station inspections were current at the time of the 524 rearward, fell on the west bank of the November 1 flight, and no authorization of Potomac River, and numerous small pieces were any type from the Administrator has been found in the Potomac Railroad Yards and on found during the course of this investigation the adjacent highway The forward portion of which would have authorized the aircraft to the aircraft fell into the river The P-38 be flown at the time of the accident had dived into the river from the point of During the time the P-38 had been on the collision Matching and mating of the vari- Washington National Airport, two external ous parts of the DC-4 fuselage, and a study 165-gallon fuel tanks had been installed, and of markings on the structure of both the DC-4 maintenance work had been accomplished on the and the P-38 showed that the P-38, at the hydraulic and fuel systems and on the radio time of impact, was at a lateral angle of equipment Insofar as the actual operation three degrees to the right of the longitudi- of the aircraft during the flight was con- nal axis of the DC-4 with the left engine cerned, no evidence of any malfunction has nacelle centered over the DC-4 --- 15354 Appendix I WASHINGTON NATIONAL AIRPORT APPROACH AND LANDING TRAFFIC PATTERN Patterns are designed for landings on each runway under VFR conditions (Caut.on Note) Heavy traffic at Anacostia, Bolling, and Andrews Field, and the area between them Remain as high as possible over residential areas and descend over water whenever possible When landing in the Northern Quadrant pass to the south of the City of Alexandria whenever possible Runway 18-36 will be utilized as much as pos- sible Takeoff bn Runway 21 or landing on Runway 3 will be utilized infrequently, depending on the force of the wind Landing on Runway 36 1 Stannard left hand pattern remain above 1200' until over the Potomac River and on final approach 2 (U,-on Request) Southwest bound traffic may use right hand pattern Pro- ceed well to the east of Anacostia ana Bolling Fields Landing on Runway 3 1 Remain above 1200s until over Potomac River, make approach over Potomac River, make left turn upon passing PEPCO plant, and line up with Runway 3 Landing on Runway 9 1 Standard left hand pattern remain above 1200' until turning on final approach Landing on Runway 15 1 Northwest bound, north bound, right hand pattern remain above 1200' until turning on base leg west of Pentagon 2 Southwest bound flight may proceed either via easr of tne Capitol or via the Northwest Passage Flights to remain above 1200' until east of Capitol or over the river at the Georgetown Reservoir (Pilots to advise on in,range report which is desired) 3 (Upon Request) Left turn in may be made - remain above 12001 until on base leg or west of Pentagon Landing on Runway 18 1 Northwest bound and north bound - right hand pattern - remain above 1200' until over me Potomac River on base leg Follow a pattern to the west and north of the Pentagon 2 Southwest bound flights may proceed either via east of the Capitol or via the Northwest Passage Flights to remain above 1200 until east of Capitol or over the river at the Georgetown Reservoir (Pilots to advise on in range report which is desired) 3. (Upon Request) Left turn in may be made - avoid restricted area Landing on Runway 21 1. Southwest bound - remain above 1200' until pass the Washington National Guard Armory 2. Southeast bound, northeast bound and north bound - remain above 1200s until turning on base leg or east of Anacostia and Bolling Fields 3 (Upon Request) Right turn in remaining above 1200' until over the river past Georgetown Reservoir Landing on Runway 27 1 Left hand pattern - remain above 1200' until on final approach 2. (Upon Request) Right hand pattern - for southwest bound flights only Landing on Runway 33 1. Left hand pattern - remain above 1200' until on final approach or over the Potomac River 2. (Upon Request) Right hand pattern - for southwest bound flights Proceed east of Anacostia and Bolling Fields and remain above 1200 until on final approach. WASHINGTON NATIONAL AIRPORT APPROACH AND LANDING PATTERN E* BfliDGL sous* BRIDGE a PHT*GOh HXJkCOSTIA BUILDING HIGHWAY BflFDGE BftkDGE L VlAG N * -.HIGHLANDS ANACOSTIA NAS WASHINGTON NATIONAL >1 rq ST LU2ABCTHS AIRPORT HOSPITAL BOLLING WVttlY A F S KILLS 3 o > o 7* o DEL ray XCN Mitt ALLXAN^RA LEGEND STANDARD --- --** BY REQUEST STATUTE MILES SiORCNM^OA.^ EXHIBIT No 7 WITNESS GATE CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT April 17, 1952 Released April 22, 1952 EASTERN AIR LINES, INC., MIAMI, FLOR I DA---SEPTEMBER 14, 1951 THE ACCIDENT to Miami, was cancelled when the aircraft Eastern Air Lines Flight 635W, a Douglas neared Fort lauderdale, Florida, and the re- DC-4, N 75415, was involved in an accident mainder of the flight was flown VFR (Visual while making a scheduled landing at Miami, Flight Rules) A few minutes after cancel- Florida, at 0633,1 September 14, 1951 Three ling the flight plan, the flight was cleared crew members, 20 adult passengers, and one to land on Runway 9L of the Miami Interna- infant were on board, no one was injured tional Airport At an altitude of 1200 feet The aircraft was substantially damaged the "in range" check was completed and the flaps were lowered 15 degrees The captain HISTORY OF THE FLIGHT said that he personally checked each item on Flight 635W originated in Boston, Massa- the check list as it was accomplished En- chusetts, September 13, 1951, with its des- tering the traffic pattern, the flight was tination Miami, Florida Intermediate stops again cleared for Runway 9L and a left turn were scheduled at New York, New York, Wash- was made to align the aircraft with this run- ington, D C , and Jacksonville, Florida, way At an approximate altitude of 800 feet with a routine aircraft and crew change to be on the down-wind leg, the "before landing" nade at New York The flight proceeded to check was made with the exception of lowering New York and from there the crew consisted of the landing gear, and the flaps were lowered Captain A C McDonough, Copilot J F to 30 degrees Turning on final approach the Reubert, and Flight Attendant R K Quinn copilot called for the landing gear to be Departure from New York was made at 2313 the lowered, and the captain said that he placed same day, and stops were made as scheduled at the landing gear lever m the full down posi- Washington and Jacksonville On departing tion He said, also, that he observed the Jacksonville the total aircraft gross take- landing gear red warning light go out, the off weight was 54,671 pounds, which was three green warning lights come on, and that within the allowable maximum gross weight of after checking and finding the hydraulic 65,705 pounds, all disposable load was dis- pressure to be normal, he placed the carbu- tributed within the approved center of grav- retor mixture controls m the full rich posi- ity limits The flight to Miami was routine tion He then called to the copilot "gear until the landing was made down and locked, three green lights, mixtures Throughout the entire flight the captain rich, you are cleared to land In addition and copilot alternated flying the aircraft, he stated that the landing gear warning light and the last portion of the flight from the dirrming switch was at the dim position, as vicinity of Vero Beach, Florida, to Miami was they had been flying through the hours of flown by the copilot Captain McDonough was darkness, and that he placed this switch in seated in the left pilots seat (his normal the bright position and again observed the place in the cockpit) and was performing the three green lights to be lighted At approx- usual copilot duties imately 400 feet above the ground the copilot The crew stated that the IFR (Instrument asked for full flaps This was done and the Flight Rules) flight plan, m accordance with aircraft was observed to approach the airport which the flight was flown from Jacksonville in a normal manner with the landing gear ex- tended When approximately 200 feet past the approach end of the runway a normal landing 1A11 times referred to herein are Eastern was made on the main landing gear wheels Standard and based on the 24-hour clock The aircraft was then seen to travel a Comm---DC---39395 (1) Obtained from RareAviation.com. 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Copyright (c) 2004 considerable distance, during which travel Ocher controls were positioned as follows the landing gear was observed to retract, cowl flaps closed, propeller controls full permitting the aircraft to settle on the bot- forward, flap indicator and flap lever full tom of its fuselage and slide to a stop A down, landing gear lever down and the landing flash fire which developed m number three gear lever solenoid safety pin in the safe engine nacelle, was quickly extinguished bv lock position, and the landing gear warning the captains use of an emergency portable light switch at the bright position An ex- hand C02 bottle and the airports fire fight- ternal examination of the aircraft revealed ing equipment All passengers were evacuated the flaps to be in the full dcwn position and in an orderly manner badly damaged by contact with the runways The Miami weather at the time of the acci- surface dent was ceiling unlimited, visibility 12 In order to determine the extent of damage miles, wind north northwest three miles per and to examine the landing gear, the aircraft hour was raised It was found that the nose gear doors were damaged by contact with the run- INVESTIGATION way, hove ver, the nose gear itself was un- Runway 9L of the Miami International Air- damaged When allowed to fall free, the nose port is 7,364 feet long The aircraft had gear extended to the full down position and come to rest 3,290 feet past the approach end locked Examination of the mam landing gear of this runway Because of tire marks from disclosed that the actuating cylinder rods of many aircraft on the runway it was impossible each gear's retract strut were bent approxi- to determine where the aircraft initially mately 90 degrees These rods had retracted touched down First discernible runway marks approximately five inches into their respec- were gouges made by the aircrafts inboard tive cylinders and were bent at a point where propellers These marks were 1,856 feet east they emerged from the packing nuts The low- of the approach end of the runway, followed er drag links of each gear were also bent a 25 feet farther on by similar marks made by few degrees The hydraulic fluid reservoir the outboard propellers Nine feet beyond was examined and it contained a normal amount these latter marks the bottom of the air- of fluid craft's fuselage made contact with the run- Functional tests were then performed way From this point the aircraft skidded Since the main landing gear doors were also until it finally came to rest, heading in an damaged, all doors were removed The hydrau- easterly direction near the center of the lic system was connected to an outside power runway, with the entire landing gear in an source and the bent main gear retract struts almost fully retracted position Damage to were disconnected from their respective land- the aircraft was confined largely to propel- ing gear assemblies The nose gear was then ler blades, engine nacelles, the bottom of extended and retracted under pressure It the fuselage, flaps and the main landing operated in a normal manner and no fluid gear leaks were found When pressure was applied, Upon arrival of the Board's investigators, the actuating rods of the main landing gears a complete record of cockpit controls, retract struts extended their full travel switches and hydraulic pressure gauge indi- distance and retracted m a normal mannei un- cations was made It was found that all til stopped by the bent portion of the rods switches, including the ignition, generator No fluid leak was found during this opera- and battery switches, were m the OFF posi- tion tion The carburetor mixture controls were The damaged actuating rods and drag links at idle cutoff position and the carburetor were then replaced by similar new parts of air controls were in the cold position The correct lengths and tolerances and the gear main auxiliary fuel and the fuel cross feed was again tested under pressure All three valves were off, and the hydraulic fluid by- landing gears functioned in a normal manner pass and hand pump valves were closed. The During this test the green warning light for emergency brake pressure gauge registered a the right landing gear did not operate, how- normal 1000 psi, and the hydraulic system ever, it was found that the micro switch op- pressure gauge registered a normal 1200 psi. erating arm for this light had been broken by impact and under finger pressure the light Should hydraulic pressure be unavailable, i functioned m a normal manner The hydraulic the landing gear could extend and lock by ics system from the landing gear selector valve own weight by operating the control lever to to the reservoir was checked No obstruction the DOWN position The design of the main was found and the reservoir filter was clean landing gear is such that the weight of the The fluid was drained from the reservoir and aircraft will hold the gear in the extended strained, no foreign matter was found The and locked position With the entire weight two engine driven hydraulic pumps were re- of the aircraft on the gear, the application moved and tested and found to function in a of full system pressure applied to the up- nonral manner The landing gear warning horn lines will not retract the gear operated normally, however, the throttles had The nose gear dovn-latch is actuated by a to be in the nearly closed position to actu- spring-loaded hydraulic bungee cylinder To ate the horn unlock this gear, up-line pressure must over- The aircrafts maintenance records were come the force of the spring With the reviewed and these indicated that normal in- weight of the aircraft on the gear, up-line spections and maintenance had been performed pressure in excess of 2500 psi is required to All airworthiness directives had been com- unlock and retract the nose gear When the plied with weight of the aircraft is on the landing gear The crew stated that the approach and the and the right main landing gear shock strut landing were made m the usual manner, that has been compressed, a safety switch actuates after the landing gear control lever was and engages the landing gear control lever placed m the down position prior to landing safety latch When this safety latch is en- it was not moved from that position, and gaged the landing gear control lever is also, that the landing gear warning horn did locked m the DOWN position not sound at any time Since the crew stated that they observed the green warning lights to be on and since ANALYSIS when subsequently tested the landing gear Since tests made subsequent to the acci- mechanism functioned properly, it can be dent showed that the aircrafts landing gear assumed that at that time the gear was down mechanism and hvdraulic system was capable of and locked From the above brief analysis functioning m a normal manner, it is neces- of the landing gears operation it would be sary to analyze the system to determine what necessary, under the conditions described, could cause the gear to retract under' such for numerous simultaneous malfunctions to conditions Normal lowering of the landing occur Although the crew stated that the gear is accomplished by moving the landing landing gear control lever was placed m the gear control lever, located m the pilot's fully down position and was not moved again, cockpit, to the DOWN position This mechan- it is probable that this lever was inadvert- ically releases the up-latches and permits ently moved upward instead of the flap con- hydraulic fluid under system pressure to en- trol lever after landing This nust have ter the down-lines, and at the same time the occurred when wing lift was still present and fluid m the up-lines is allowed to return to there was insufficient weight on the landing the reservoir The landing gear then extends gear strut to actuate the landing gear con- and locks, and the svstem pressure builds up trol lever safety latch This is substan- to 2700-3000 psi As the down-latches en- tiated by the manner m which the actuating gage, the green lights come on and the red cylinder rods were partially retracted warning light goes out The landing gear is then held in the extended position by the FINDINGS down-latches and the system pressure which is applied to the down-lines Strong spring On the basis of all available evidence the bungees hold the down-latches m the locked Board finds that position The hydraulic fluid m the down- lines is then trapped by means qf a check 1 The carrier, the crew and the aircraft valve at the in-port of the control valve and were properly certificated cannot escape until the control valve is 2 The copilot was sitting m the right placed m the UP position pilots seat and was flying the aircraft 3 The flight was cleared to enter the PROBABLE CAUSE Miami traffic pattern and landing gear was The Board determines that the probable lowered cause of this accident was the inadvertent 4 Following the lowering of the landing moving of the landing gear control lever up- gear, the green warning lights came on indi- ward during the landing roll, causing the cating the gear was fully extended and landing gear to retract locked, pressure normal BY THE CIVIL AERONAUTICS BOARD 5 A normal landing was effected and dur- ing the landing roll the entire landing gear Is/ DONALD W NYR0P retracted /s/ OSWALD RYAN 6 The landing gear was found capable of /s/ JOSH LEE functioning m a normal manner when tested Is/ JOSEPH P ADANS after the accident /s/ CHAN GURNEY Supplemental Data INVESTIGATION AND HEARING He was the holder of a valid airman certifi- The Civil Aeronautics Board received no- cate with an airline transport, multi-engine tification of the accident through the East- land 820-12500 h p ratings Captain ern Air Lines office at the Miami Interna- McDonough had a total of approximately tional Airport at 0725, September 14, 1951 12,872 flying hours, of which 2,145 were in An investigation was immediately initiated DC-4 type equipment His last instrument in accordance with the provisions of Section check was accomplished May 4, 1951 His 702 (a) (2) of the Civil Aeronautics Act of last CAA physical examination was success 1938, as amended A public hearing was held fully passed July 26, 1951 m connection with the investigation of this Copilot J F Reubert, age 30 was employed accident at Coral Gables, Florida, October by Eastern Air Lines July 15, 1946 He held 30 and 31, 1951 an airman certificate with a commercial pilot, single and multi-engine land and in- AIR CARRIER strument ratings He had a total of 2,451 Eastern Air Lines, Inc , is a Delaware flying hours, of which 336 were m DC-4 type corporation with its principal place of equipment His last CAA physical was accom- business at Miami, Florida Eastern Air plished May 3, 1951 Lines possesses a certificate of public con- The other crew member was Flight Attendant venience and necessity issued by the Civil Rowland Quinn Aeronautics Board and an operating certifi- cate issued by the Civil Aeronautics Admin- THE AIRCRAFT istration These certificates authorized the carriage of persons, property, and mail N 75415, a Douglas DC-4, was manufactured over the routes described m this report July 5, 1944 An examination of all his tor- ical maintenance and inspection records of FLIGHT PERSONNEL this aircraft disclosed no items which had Captain A C McDonough, age 40, was em- any particular significance m respect to ployed by Eastern Air Lines October 9, 1939. this accident ---39395 SA-268 File Ho. 1-0001 CIVIL AERONAUTICS BOARD CCIDENT INVESTIGATION REPORT Adooted: June 17, 1953 ReI eased: June 19? 1953 THE FLYING TIGER LINE, INC., - DOUGLAS DC-U, ISSAQUAH, WASHINGTON JANUARY 7, 1953 The Accident At approximately 2055, January 7, 1953, a Douglas DC-1, N 86571, owned and operated by The Flying Tiger Line, inc., crashed two males south of Issaquah, Washington, during an instrument approach to Boeing Field, Seattle, Washington. All seven occupants were killed. The aircraft was demolished by impact and fire. History of the Flight Flying Tiger's Flight 8I4I of January 7, 1953, a ferry flight from Burbank, California, to Seattle, to pick up military personnel, was made in accordance with the company's contract with the Depar treat of National Defense. Depar- ture from Burbank was at 1L37, with Captain C. Greber, pilot in command, Captain B. Merrill, and Copilot W. Lowe comprising the crew. Captain H. Wall, chief pilot of the conpany's Burbank Division, was on board as an observer. The weight of the aircraft at takeoff was 57,520 pounds which was within the maximum allowable gross weight; there was no revenue load. Throughout the segment of the flight to San Francisco, California, Captain Merrill and Captain Lowe flew the aircraft; with the exception of a false fire warning signal from the No. 3 engine nacelle observed in the cockpit shortly after takeoff, the flight to San Francisco was routine. Upon arrival there mechanics checked the fire warning system and found no evidence of a fire having occurred. Captain Merrill told the mechanics that he was satisfied from their inspection there was no danger of fire and that he would not delay the flight further. The mal- functioning fire warning system was not repaired at this time. Captain 'Jail terminated his flight at san Francisco and a company stewardess, together with a woman passenger and her two children, (the wife and children of a company pilot), boarded the aircraft at this point to fly as non-revenue passengers. No fuel or cargo was added at, San Francisco. Flight 8hl departed San Francisco at 1737 with Captain Greber in command occupying the left pilot's seat and Captain Merrill occupying the copilots seat. The flight was cleared by ARTC (Air Route Traffic Control) to fly VFR via Amber Airway No. 1 to Williams, California, and IFR from Williams to Boeing Field, Seattle, at an altitude of 11,000 feet MSL. The estimated time en route was three hours and 39 minutes with 1,500 gallons of fuel on board and the Seattle-Ta coma Airport was designated as the alternate. 1/ All times referred to herein are pacific Standard and based on the 21t-hour clock. 5183 Normal en route position reports were made by the flight and at 1947 it reported being over Eugene, Oregon, at 11,000 feet. Seattle ARTC then cleared the flight to descend to and maintain 9,000 feet until passing Portland, Oregon, and from this point, to descend to and maintain 7,000 feet. At 2036 flight 841 reported over the McChord radio range station and re- quested further clearance. Accordingly, ARTC cleared the flight to maintain 7,000 feet, to contact Seattle Approach Control immediately and advised that no delay was expected Contact was immediately made with approach control; the flight was then cleared to make a standard range approach to Boeing Field and requested to report leaving each 1,000-foot level during the descent. The following weather information was given the flight at this time: "Boeing Field - 1800 scattered, 2200 overcast, 8 miles, wind south-southeast 22, gusts to 30, altimeter 2925j Seattle-Tacoma - measured 1900 broken with 3100 over- cast." Flight 841 acknowledged this clearance and reported leaving 7,000 feet at 2040. Two minutes later, at 2042, it reported being over the outer marker and leaving the 6,000-foot level. No report of leaving the 5,000-foot level was made aid at 2045 the flight advised it was leaving 4,000 feet. When the latter was acknowledged by approach control the flight was further advised as follows: "If youre not VFR by the time you reach the range you can shuttle on the northwest course at 2,000 feet, it's possible you'll break out in the vicinity of Boeing Field for a south landing." The flight acknowledged at 2050 and said it was leaving 3,000 feet. At the time N 86574 was making the approach to Boeing Field, a Pan American DC-4 aircraft was also approaching this airport from the northwest. The latter aircraft had been advised by approach control that it was No. 2 to land behind the Flying Tiger aircraft in the traffic pattern, The Pan American aircraft was making a routine let-down on the northwest leg on the Seattle range and at 2054 reported being at the 3,000-foot level and VFR. Immediately after receiving this altitude report approach control called N 86574 and advised: "You're clear to contact Boeing Tower on 118.3 for landing instructions." This was acknowledged by 'Roger" and was the last known contact with the Flying Tiger aircraft. At approximately 2055, N 86574 crashed about 11 miles east of the Seattle range station at the base of Squak Mountain. All seven occupants were killed and the aircraft was demolished by impact and the ensuing fire. Investigation The aircraft first struck a high tree on a mountain ridge at an elevation of 1,620 feet. The location of the impact was approximately one-half mile east of the summit of Squak Mountain (elevation 1,980 feet MSL) on which radio towers are located. Following impact with, the tree the aircraft continued flying and finally struck the ground in a canyon 1500 feet below. The aircraft was in a nearly vertical attitude on impact with the ground and the velocity was such that the engines and cockpit were bedded deep in the soft muddy loam. Pieces of wreckage were scattered in all directions, and fire destroyed a considerable portion of the aircraft. Examination of the wreckage revealed thatQthe landing gear was fully re- tracted and that the wing flaps were in the 25 down position when the accident occurred. Because of the damaged condition of the cockpit it was impossible to obtain ccntrol settings or instrument readings. The upper portion of the aircraft's vertical fin, a section of the engine cowling, the No. 2 propeller with reduction gearing attached, and the major portion of the rudder were found on the mountain ridge within a l^OO-foot radius and in a northeasterly direction from the base of the damaged tree. A subsequent tear-down and inspection of the propeller hubs and engines indicated that all propellers were in the cruise range at impact and that all engines were rotating. Unused cabin fire extinguishers were found in their respective brackets; how- ever, the brackets had been torn from their mounts. All CC^ bottles had broken necks and two of these bottle necks were recovered with their seals un- punctured. Due to the disintegration of the cockpit and cabin areas, the bodies of the three-man crew could not be associated with specific seating positions. No evidence was found which indicated the existence of fire, structural failure, or malfunctioning of the aircraft or its components prior to impact with the tree. 2/ There are three airports in the immediate Seattle area---. When approach- ing from the south, Seattle-Tacoma is the first airport encountered. Seattle- Tacoma is a large airport with four surfaced runways and lies to the west of the southwest leg of the Seattle range, approximately four miles southwest of the range station. Boeing Field is located on the northwest leg of the Seattle radio range 2.1 miles from the range station. Renton Airport is located approximately two miles east of the range station on the southeast leg of the range. Both Boeing Field and Renton have single runways oriented north vest to southeast. Boeing Field is equipped with high intensity runway lights and Renton has a low intensity runway lighting system. Two witnesses who were working at the Renton Airport at the time the subject aircraft was making its approach stated that a large four-engined air- craft crossed that airport at a low altitude and that it disappeared from their view in a northeasterly directiczi. Other ground witnesses at various locations north and northeast of this airport reported seeing a large aircraft flying toward the north or northeast-'. In each instance, the aircraft sighted was flying at a low altitude with engines operating in a normal manner, and there was no indication of fire aboard the aircraft. Several witnesses stated that after seeing the aircraft, they saw in the direction it had flown, a large orange glow, which appeared to them as if a ball of fire was falling toward the earth. Some of these witnesses also heard an explosion. Those witnesses in the vicinity of the scene of the accident said that the lighted radio towers located on Squak Mountain were not visible to them because of clouds, and that at the tune of the accident a heavy rain was falling which was accompanied by strong gusty surface winds. N 86^7h was equipped with two low frequency radio receivers, two ADF (Automatic Direction Finder) receivers, a VHF transceiver and Loran radio equipment. Of this equipment, one low frequency receiver, one ADF and the VHF were recovered. The low frequency receiver was found tuned to 260 kc e th frequency of the Seattle radio range station; the ADF receiver was tuned to 2/ See Attachment. 3/ The accident occurred approximately nine miles east and north of Renton Airport. Obtained from RareAviation.com. See our selection. Copyright (c) 2004 201 kc., the frequency of the ILS (instrument Landing System) middle marker for the Seattle-Tacoma Airport, and the VHP communications transceiver was tuned to 119-5 kc., the frequency of Seattle Approach Control. The pilot of the Pan American aircraft which was approaching Boeing Field from the northwest when the accident occurred, said that uhe weather conditions in that area were substantially as reported and that he was vianal 1 y contact at 3,000 feet. He also said that the ground navigational facilities were operating in a normal manner that all radio common ications between these facilities and hisflight appeared to be clear and reasonably free of static. The pilot said that he could not state what the weather conditions were northeast of the Seattle range station as he dad not fly any farther east than this station. All three crew members of the Flying Tiger aircraft had current air trans port rating certificates with appropri e aircraft and horsepower ratings, Captain Merrill and First Officer Lowe were acquainted with the route in- volved and had flown to Seattle and landed at Boeing Field within the previous six months. Captain Q?eber had not flown to Seattle since being employed by the company in 1951. He had recently transferred from the east coast where he had been working for the company, and in recent weeks had been appointed by the CAA as a designee check pilot A check with the proper CAA authorities disclosed that no other aircraft were known to be flying in the area other than those previously mentioned at about the time this accident occurred. All CAA navigational facilities were both ground and flight checked immediately following this accident and found to be within proper tolerances. Analysis A study of the known facts, conditions and circumstances surrounding this accident points to but one conclusion - that it was operational in character. To summarize briefly: First, the ceiling of the clouds, the wind, the mild turbulence and the visibility was such that a safe approach and landing should have been consummated; second, the radio facilities available for navigational purposes were functioning in a normal manner and static interference at the time was negligible; third, there is no evidence which indicates a fire or any- malfunctioning of the aircraft or its components prior to first impact; fourth, the companys approved low frequency range approach procedure for an q?proach from the south to Boeing Field is both safe and correct. If executed properly, a turn to the right or east should not be made after once aligning the aircraft with the southwest leg of the range inbound except for possible slight corrections. There is no reasonable explanation to account for the presence of the air craft in the sector where the crash occurred, which is approximately 11 miles to the right and east of the range station. It is possible that the pilot became confused and for a few moments thought Renton Airport, which lies 4/ It is not known which crew members were occupying the pilot's seats at the time the accident occurred. slightly to the right of course, was Boeing Field} however, following such a mistake corrective action would not permit a course to be taken in a north- easterly direction which would lead the aircraft toward the mountains, instead an immediate turn to the left should have been made to contact the northwest leg of the range. In fact, such instructions had already been issued the flight in the event it was not visually contact upon reaching the range. Pilots unfamiliar with the area have in the past, under similar con- ditions, mistaken Renton Airport for Boeing Field; however, if the approach procedure to Boeing Field had been correctly followed this could not have occurred. Fmdings On the basis of all available evidence the Board finds that: The carrier the aircraft, and the crew were properly certificated 2. The aircraft lid not carry any cargo and there was sufficient fuel aboard for the flight with a considerable reserve The flight was properly cleared to make a standard instrument approach to Boeing Field h. Although instrument weather conditions prevailed at the time of the approach to Seattle, no unusual weather existed which should have prevented the approach being made according to approved procedures The pilot of the aircraft deviated from the established approach pro cedure by flying 11 miles to the east of course 6. All ground navigational aids were functioning normally There was no indication of fire or malfunctioning of the aircraft or any of its components prior to first impact Probable Cause The Board determines that the probable cause of this accident was the flights deviation from the established approach procedure to Boeing Field. BY THE CIVIL AERONAUTICS BOARD: 4 /s/ JOSH LEE /s/ JOSEPH P. ADAMS /s/ CHAN GURNE Oswald A1111 refOTt- SUPPLEMENTAL DATA Investigation and Hearing The Civil Aeronautics Board was notified of this accident at 2220, January 7, 1953, by CAA Communications at Seattle. An investigation was immediately initiated in accordance with the provisions of Section 702 (a) (2) of the Civil Aeronautics Act of 1938, as amended. A public hearing ordered by the Board was held at the Washington Athletic Club, Seattle, Washington, January 29 and 30, 1953- Air Carrier The Flying Tiger Line, Inc., is a scheduled air carrier incorporated in the state of Delaware with its principal business office at Burbank, Califor- nia. it operates under a currently effective certificate of public conven- ience and necessity issued by the Civil Aeronautics Board and an air carrier operating certificate issued by the Civil Aeronautics Administration. These certificates authorize the company to transport cargo by air over numerous routes within the continental limits of the United States including the route involved. The subject flight was conducted under an exemption granted by the Civil Aeronautics Board which authorizes the carrier to engage in interstate, overseas, and foreign air transportation of persons, pursuant to contracts with any department of the military establishment. Flight Personnel Captain C. E. Greber, age 32, held a currently effective airline trans- port pilot rating with an appropriate rating for the subject aircraft. He had a total of 8,590 flying hours, of which 2,0^0 had been in DC-4 type air- craft. He had passed his last CAA physical examination on December 18 1952, and had been employed by the company since 1950 J ft Captain B. M. Merrill, age 48, held a currently effective airline trans- port pilot rating with an appropriate rating for the subject aircraft. He had been employed by the company since 1950. He successfully passed his last CAA physical examinaton on Decent er 10, 1952. He had accumulated a total of 14,961 flying hours, of which 8,060 hours had been in DC-4 type aircraft First Officer W. C. Lowe had been employed in that capacity by the company since 1952. He held a currently effective airline transport pilot rating and had successfully passed his last CAA physical examination on September 11, 1952. He had accumulated a total of 3,980 flying hours, of which 837 hours were in DC-4 type aircraft. The Aircraft N 86574, a Douglas Model C-5hB, was owned and operated by The Flying Tiger Line, Inc. The aircraft was manufactured August 8, 1944, and had a total of 20,078 hours of operation. It was equipped with Pratt and Whitney R-2000-7 engines and the propellers were Hamilton Standard, The aircraft was properly certificated and there was no evidence to indicate that it was not airworthy. MINIMUM SAFE ALTITUDES 100 Nautical Miles 16500 25 Nautical Miles 7200 MIN ALT NAS SE Attle N ELEV 17 2800 25 Ml|/ ----RBn---- 37 SEATTLE RADIO NAS SEATTLE ) RADIO 260 SEA 532 WN =~ o 126 7 135 0 135 9 BOEING 70WER 278 118 3 126 18 KURTZER Consult radio facility charts 74 o Oo For latest information LAKE UNION Gal. #3 hOO Gal. #L hop Gal. Auxiliary Tanks #1 10 Gal. #2 O'Gsa. i^3~ 6 Gal. LOO~Gal. TEST ONE: Altitude 8,000 feet Fuel System Configuration Engines 3 and U drawing fuel from No. 4 Auxiliary Tank No, 3 fuel selector OFF. No. h fuel selector AUXILIARY position Right crossfeed CENTER POSITION, "Crossfeed between Engines 3 and U." Boost pumps OFF. R. m. 1,950; Manifold Pressure 29.6" Mixture controls engines 3 and 1* AUTO LEAN In the above configuration, engines 3 and 4 operated normally Hie No. 3 fuel selector was moved to the AUXILIARY pbaition and the right crossfeed was shut OFF. After shutting off the right crossfeed the Nd. 3 engine ran for U2 seconds before the fuel pressure dropped to 3-h p. s TEST TWO: Altitude 8,000 feet Fuel Selectors Nd. 1 AUXILIARY position; No. 2 No. 3 No. h AUXILIARY position Crossfeed Left - CENTER, "Crossfeed Between 1 & 2." Right CENTER, "Crossfeed Between 3 & 4.1 Booster Pumps OFF Mixture AUTO LEAN. 1,9^0; Manifold Pressure 29.6" Fuel Pressure No. 1 I7i# No. 2 17^#. Engines No. 1 and No. 2 were allowed to run No. 1 auxiliary tank dry. No. 1 quit at 1121 P. a. t. Fuel pressure dropped to 3-4 p. s. i. on N prior to engine quitting. After No. 1 engine quit, the No. 2 fuel selector was moved to the AUXILIARY position, the left crossfeed was shut OFF, and the Nd. 1 and No. 2 main boost pumps were turned ON. ine No. 2 fuel pressure dropped to 3-4 p. s. i., and No. 2 engine quit at 11211 P. s. t. After No. 2 engine quit, No. 1 and No. 2 engines were allowed to windmill for 42 seconds t which time the No. 1 and No. 2 fuel selector valves were moved to the MAIN TANK positions After moving the No. 1 and No. 2 fuel selectors to the main tank positions, engines No 1 and No. 2 fuel pressures rose to 18-19 p, t i. and the engines recovered cruise power in 3 to 4 seconds. Altitude 8,000 feet R. p. m. l,950j Manifold Pressure 29.6n. Engines No. 3 and Nd. 4 drawing fuel from No. 4 AUXILIARY tank. Right crossfeed on CROSSFEED BETWEEN 3 & 4. No. 3 fuel selector OFF. Engine operation normal* No. 4 fuel selector was shut OFF, and the No. 3 fuel selector moved to AUXILIARY position. Crossfeed not moved. Engine No. 4 fuel pressure dropped to 3-4 Engine No. 4 fuel pressure dropped to 3-4 p. s. i. and No. 4 engine quit, One minute, 15 seconds later, No. 3 fuel pressure dropped to 3-4 p. s. i. and No, 3 engine quit. Engines No. 3 and No. 4 were allowed to windmill three minutes, at which time the No. 3 fuel selector was mo zed to the MAIN TANK position, booster pumps OFF. Engine No. 3 recovered normal fuel pressure and cruise power in five seconds. No. lx likewise recovered in seven seconds. TEST FOUR: Altitude 10,000 feet m. 1,950; Manifold Pressure 29.6" Fuel quantities Fuel selectors 1, 2, 3, and 4 put in AUXILIARY positior Crossfeeds OFF Engines No. 1, No. 2, and No. 3 allowed to quit and windmill for three minutes. Fuel pressure at tine engines 1. 2, and 3 quit, 3-4 P. s. 1.: engine No. 4, 18 P- s i No. 4 auxiliary boost pump was turned ON HIGH, and both crossfeeds were moved to FULL FORWARD position, nAll Engines to Crossfeed.9 No. 4 fuel pressure re mained steady at 18| p. s. Engines No. 1, No. 2 and No. 3 recovered cruise power and normal fuel pressure in eight seconds No. 2 engine came back in first, followed by Engines No. 1 and No. 3. TEST FIVE Altitude 10,000 feet. R. p. m. l,9!>0; Manifold Pressure 29.6 Fuel loading Auxiliary Tanks No. I Empty; No. 2 Empty; No. 3 Empty; 4 100 Gal. Level flight, all engines on respective MAIN TANKS. Engine operation normal all engines. Booster pumps OFF. Crossfeeds OFF All four fuel selectors were moved to AUXILIARY position. Engines No. 1, No. 2, and No. 3 allowed to quit due to fuel starvation, and to windmill for two minutes, at which time both crossfeed valves were moved to the FULL FORWARD position, "All Engines to Crossfeed;* booster pumps OFF. No. 3 engine recovered normal fuel pressure and cruise power in ten seconds Engine No, 4 was not affected. Engines No. 1 and No. 2 fuel pressure remained 3-4 p. s. i. with engines windmilling Takeoff power was applied to the No. 4 engine. No 4 fuel pressure fluctuated, No. 3 fuel pressure dropped to 3-4 and No. 3 engine quit, after which No. 4 fuel pressure dropped to 3-4 p. s. 1 4 engine quit. The throttles were closed on engines 1, 2, 3, and 4, and the No. 4 auxiliary boost pump was turned ON HIGH. All four engines fuel pressure returned to normal operating range, and all engines started in approximately three seconds after the No. 4 auxiliary boost pump was turned on. TEST SIX; Altitude 10,000 feet. CRUISE POWER 1, 2, 3, 4 engines. Fuel selectors 1, 2, 3, 4 on MAIN tanks Crossfeeds OFF. Fuel loading Auxiliary Tanks No. 1 Empty; No. 2 Empty; No. 3 Empty; No. 1| 80 Gal. (Approx.) All four fuel selectors were moved to AUXILIARY positions, and engines 1, 2, and 3 were allowed to quit due to fuel exhaustion, and to windmill for two minutes. FULL POWER was applied to No. U engine. Left and right crossfeeds were moved to "ALL ENGINES TO CROSSFEED positions. Nd. I4. fuel pressure remained steady and engine ran normally. No. 2 engine came back in with normal fuel pressure in eight seconds ran for 30 seconds, then quit as fuel pressure dropped to 3-U p. s. i. N fuel pressure dropped to 3-U p. a. 1. 15 seconds later, and No. U engine also quit. Fuel pressure on engines 1 and 3 remained at 3-U p. s. i. and the engines windmilled throughout this portion of the test. he No. 4 rnixiliary boost pump was turned ON HIGH id all four engines recovered normal fuel pressure and came back in at reduced throttle wetti ngg in seven seconds. During the tests described above* the ignition switches for all engines remained on BOTH at all times, and the mixture controls were set as noted or in AUTOMATIC RICH position. CIVIL AERONAUT ICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: January 31 1955 Released: February 3, 1955 GREAT LAKES AIRLINES, INC., AT GAGE, OKLAHOMA, JUNE 15, 1954 The Accident A Douglas C-54-G, N 30070, operated by Great Lakes Airlines, Inc., made an emergency landing off the runway at the Gage Oklahoma Airport, at 0320 on June 15, 19511.2/ The emergency landing was made because of an uncontrollable fire in the number 3 engine nacelle. There were no injuries to passengers or crew. The aircraft was destroyed by fire. History of the Flight Great Lakes Airlines' Flight 146, of June 14, 1954, originated at New York, New York, with its destination Burbank, California, and with intermediate planned stops at Chicago, Illinois, and Kansas City, Missouri. The segments of the flight to Kansas City were made without incident and the aircraft landed there at 0005, June 15, 1954. At Kansas City a routine crew change was effected and the aircraft was refueled. Hie new crew consisted of Captain Charles F. Pedesky, First Officer Frank J. MacDonald, Jr., and Stewardess June E. Miller. No service was per- formed on the aircraft at Kansas City other than refueling. According to company records the takeoff weight of the aircraft was 71,1113 pounds, which was within the allowable limits and the load was properly distributed with respect to the center of gravity of the aircraft. Prior to takeoff Captain Pedesky made a preflight inspection and no discrepancies were noted. The flight, normally dispatched, departed Kansas City a"t 0107 and was cleared ZFR (Instrument Flight Rules) to Burbank, California, via Green 4 and Amber 1, to cruise and maintain 4,000 feet. The estimated en route time was 7 hours and 40 minutes and there was sufficient fuel for a flight of 11 hours and 30 minutes. There were 75 adult passengers and 4 infants on board. At 0213, when the flight was over Wichita, Kansas, a routine position re- port was made in which it was estimated that the flight would be over Gage, Oklanoma, at 0307. The crew testified that when the aircraft was in the vi- cinity of Gage radio reception was poor due to static caused by local thunder- storms m that area. At approximately 0305, Gage INSAC, (Interstate Airways Communications) advised the flight that Albuquerque ARTC (Air Route Traffic Control) cleared it to climb and maintain 6,(X)0 feet, Accordingly, Flight 146 began to climb. Shortly thereafter the stewardess entered the cockpit and 1/ All times referred to herein are Central Standard and based on the 24-hour clock. told the pilots that she had seen sparks trailing from number 3 engine. The captain immediately requested the first officer to look out of his window and see if he could see anything wrong. This was done but nothing unusual was seen. At the same tune the captain checked the instruments and found their indications to be normal. The stewardess was then told to return to the cabin and to again advise the captain if and when she observed anything out of the ordinary. At approximately 0308, when the aircraft was at an altitude of 5,500 feet and in the vicinity of Gage, the zone 2 fire warning light of the number 3 engine came on. As soon as this was observed the first officer went to the cabin to make a visual check. He returned a few seconds later and reported there was a fire m the number 3 engine. The captain immediately returned the aircraft to level flight and feathered the number 3 propeller. The fire- wall shutoff valve was then pulled, the COg selector set for the number 3 en- gine and the first bank of CO2 bottles was discharged. As this application of carbon dioxide did not appear to put the fire out the engines cowl flaps were closed and the second bank of CO 2 bottles was discharged. Following this action the fire was seen to momentarily die down but almost immediately to flare up again. The first officer called Gage INSAC at approximately 0312 while the cap- tain was performing these duties and advised that the number 3 engine was on fire and that its propeller had been feathered. Ty Gage INSAC communicator immediately turned on the airport runway lights for the north-south runway. There were no other radio contacts with the flight. Captain Pedesky, unable to extinguish the fire, began a left descending turn toward the airport. During this turn the number 3 engine fell from the aircraft at which time a complete failure of the electrical system was ex- perienced. The captain testified that throughout the approach he was unable to see the runway lights on the airport and, not being able to use the air- craft's landing lights, he headed m the general direction of the airport beacon. Throughout the latter stages of descent the first officer used a flash light so that he could observe and call out altimeter and airspeed readings. As the aircraft neared the ground the fire illuminated the surface permitting the captain to see the ground and land the aircraft safely. After rolling a considerable distance the right main landing gear collapsed. When the aircraft came to a stop all passengers were quickly evacuated. Fire eventually destroyed the aircraft. The Gage weather at the time of the accident was: ceiling estimated 12,000 feet, overcast, visibility 15 miles, thunderstorms, wind south-south east 10 miles per hour. Weather was not a factor in this accident. Investigation Investigation conducted at the scene of the accident disclosed that the aircraft first contacted the ground on a heading of 110 about 900 feet to the left of runway li (0U0) and 1,000 feet inside the airport boundary After rolling approximately 1,100 feet the right: nain landing gear collapsed because of fire damage and the aircraft then ekidded sideways to the right stopping 1,800 feet from the first ground contact point. The captain ordered an im- mediate evacuation of the aircraft, which was done quickly and in an orderly manner through the main cabin and pilot doors. Evacuation was accomplished in an estimated 1-1/2 minutes without serious injuries to any of the passen- gers or crew. The intense fire m the number 3 nacelle area continued to bum, spreading progressively throughout the entire aircraft with the excep- tion of the left wing and empennage. The INS AC communicator at Gage stated that at the time the aircraft re- ported to him he did not receive the information that the aircraft's engine was afire but only that a propeller had been feathered. Another flight oper- ating in the range of Gage, however, heard the flight report the engine was also on fire When the operator learned that fire was existent the flight had already made its emergency landing. The communicator, alone on duty, was unable to leave his position to go outside because of his attention to radio operation He was also unable to see the airport landing area from his posi- tion, therefore, he did not see the aircraft coming toward the airport or see it land. He did not know that the aircraft had landed until the crew entered his office and advised that it was on the field and burning; also that the Gage Fire Department had been notified by the Captain. The fire truck arrived approximately 30 minutes later. The equipment consisted of 2 CO2 bottles and a water tank, operated by volunteer firemen, and was not designed for combat- ing an aircraft fire but for the use of the small community of Gage, Oklahoma. The number three engine, which fell from the aircraft, was found 11 miles northwest of the airport It, being the area of the origin of the fire, was given exhaustive examination The nose case of the engine was demolished by impact and cylinders 8, 9, 10, 11, and 12 were severely damaged by impact and fire. The diffuser section and accessory case were destroyed. Only portions of the accessories normally installed on the rear case were recovered; all had sustained fire damage. Disassembly of the engine indicated that there was no failure or malfunction prior to impact. The generator for this engine, a Jack and Heintz Model JH 11300, type R-2, serial number 772, was recovered. It was badly damaged by the intense fire and impact. Disassembly revealed that the inner and outer races of the front bear- ing were badly galled and distorted. Three accessory case generator mounting studs were recovered. Two were 6-1/2 inches long and were bent about five de grees at the point where they passed through the generator mounting flange. The third stud had failed in tension and bending t approximately the same place where the others were bent Only the inner race of the rear generator bearing was found It was still attached to the drive shaft and armature sup- port tube Approximately 1/k of the circumference of the forward and rear edges of the bearing groove was cut, distorted, and rolled The generator drive shaft was broken just aft of the clutch assembly The shear section of the shaft, designed to fail under excessiv e loads, was intact although bent one degree. The armature and commutator components of the generator were severely scored, distorted, and burned. The score marks on the armature matched similar ones on the coils and interpoles and were rotational in direc tion which indicated they were made while the armature was still turning. According to conpanj recorcs the generator had accumulated 550 flight hours since overhaul. The overhaul included replacement of the front bearing Investigation further disclose that the Douglas C-5UG electrical system originally consisted of fou 100 ampere generators, one installed on each engine. This system was subsequently modified on the subject aircraft by the carrier in favor of a two 300 ampere generator system, a generator mounted on number 2 and number 3 engines. The modification was made in accor- dance with a CAA approved Delta-C&S Airline engineering order number 336 dated July 29, 19^6. The modification was made to provide a more efficient generator system for the aircraft. In the specific instance of N 30070 the modification was completed and approved November 15, 19 53. Generators specified by the engineering order were designated as type G-27. It was learned through testimony of the manufacturer's representative that the R-2 generator, the -type installed on the number 3 engine, was identical with the generator specified m the engineering order After World War 11 a large sur plus of the R-2 generators, both new and used, were released by the Air Force Jack and Heintz, therefore, in order to identify their own surplus stock from any other, both as to sales and warranty, designated theirs as the G-27 gener ator. Exhaustive examination was conducted relative to the airframe, the other engines, and propellers, and although these components were badly damaged from impact and fire no evidence could be found of malfunction or failure prior to impact. The crew stated that prior to the fire they experienced no mechanical or structural discrepancies. Investigation and examination of the wreckage definitely indicated that the failure of a generator bearing was the initial malfunction. This failure resulted in the generation of extreme frictional heat capable of weakening and burning through adjacent fluid lines causing the release of inflammable fluids which were ignited. The fire progressed so rapidly and became so intense that available CO2 was insufficient to extinguish it. The failure of the generator drive shaft to shear at its designed shear section after the bearing failure, permitted the generation of extreme friction heat and -the release of inflammable fluids with consequent intense fir The loss of all electrical power at the time the engine separated from the aircraft was most probably caused by a ground fault on the power cables during the physical break up of the nacelle installation Further radio contact with tiie Gage INSAC and the use of the aircrafts landing lights were prevented by the electrical power loss The landing was made on the airport off the runways due to the surface type runway lights being obscured by a growth of tall grass This tall grass was normally mowed 5 feet on either side of the runways and unless an aircraft, on approach, was lined up with a runway the lights would not be visible from a low approach as in this incident. The Gage INSAC com- municator testified that he did not hear any mention of fire when the flight contacted him. It is probable that static and interference from other radio receivers prevented him from hearing the complete message. Before further transmission from the aircraft could be made all electrical power was lost, consequently the Gage Fire Department was not at the airport when the air- craft landed. It is doubtful that the available fire equipment would have been able to extinguish the fire had it been alerted and present at the time of the landing. The Board wishes to commend both Captain Pedesky and First Officer MacDonald who, under the emergency conditions present, effected a safe landir at night, without aircraft lights and only the airport beacon as guidance. Miss Miller, the stewardess, is also to be complimented for the prompt and efficient manner m which she supervised the evacuation of all passengers fro the burning aircraft without injury to any of them. Findings Upon consideration of all available evidence the Board finds that: carrier, the aircraft, and the crew were properly certificated 2 The flight was dispatched in accordance with company procedures The total weight at takeoff was 71,1^3 pounds which was less than th maximum allowable and the disposable load was properly distributed with respe to the center of gravity of the aircraft u. The flight was routine until, when in the vicinity of Gage, Oklahoma fire occurred in number 3 nacelle. 5. A generator bearing failure resulted in extreme frictional heat wine weakened or burned through adjacent inflammable fluid lines and ignited the fluid. 6. The intense fire caused the number 3 engine to drop off m flight resulting in a complete loss of electrical power. Probable Cause 4 The Board determines that the probable cause of this accident was a bearing failure of the number 3 engine generator causing extreme frictional heat and the release of inflammable fluid which ignited in flight. BI THE CIVIL AERONAUTICS BOARD: /s/ CHAN GURNEY /s/ HARMAR D. DENNY /s/ JOSEPH P. ADAMS SUPPLEMENTAL DATA Investigation and Hearing The Civil Aeronautics Board was notified, of the accident at 0445, June 15, 1954. An investigation was immediately initiated m accordance with the provisions of Section 702 (a) (2) of the Civil Aeronautics Act of 1938, as amended. A Special Investigation was held and depositions were taken at FortWbrth, Texas; Kansas City, Missouri; Santa Monica, California; and Maple Heights, Ohio. Air Carrier l ' Great Lakes Airlines, Inc., is a large, irregular carrier, incorporated in the State of New York, with its principal place of business in Burbank California. It operates under Letter of Registration No. 810 issued by the Civil Aeronautics Board and an operating certificate issued by the Civil Aeronautics Administration. These certificates authorize the company to transport by air persons or property within the continental limits of the United States. Flight Personnel Captain Charles F. Pedesky, age 30, was employed by the company April 1, 1950. He held a currently effective airline transport certificate with an appropriate rating for the subject aircraft. He had a total of 8,000 flying hours of which 2,750 were in C-54 type equipment. His last CAA physical examination was accomplished February 26, 1954. First Officer Frank J. MacDonald, Jr., age 33, was employed by the company May 27, 1953. He held a currently effective airman certificate with commercial, multi-engine land, and instrument ratings. He had a total of 9,100 flying hours of which-200 were in 0-54 type equipment. His last CAA physical examination was accomplished March 18, 1954. Stewardess June E. Miller was anployed by the comp ary June 30, 1953. The Aircraft N 30070, a Douglas C-54-G, was owned by the United States Air Force and was leased to Great Lakes Airlines February 1950. The aircraft was currently certificated by the Civil Aeronautics Administration and had a total of 21,923 flying hours. It was equipped with Pratt and Whitney Models R-2OOO-9M4 and R-2000-9 engines and Hamilton Standard 23E50-505 propellers. CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: June 30, 19*19 Released: July !, 1949 Mb NATIONAL AIRLINES, INC., TAMPA, FLORIDA, SEPTEMBER 8 19U8 The Accident it was cleared by the Tampa Tower to At approximately 1352,* September 8, make a straight-in approach for a land- 1948, National Airlines Flight 72, a ing on Runway 27 Douglas DC-4, NC-33682, en route from Two and one-half miles southeast of Miami, to Tampa, Florida, experienced a the airport, when the landing gear and fire in the No. 3 engine nacelle. The flaps were extended for landing, an ex- flight landed at 1405 at the Tampa Inter plosion occurred in the No. 3 engine na- national Airport. celle. Following the explosion, the aircraft vibrated violently and direc- History of the Fl ight tional control became difficult co raain- Flight 72 departed from Miami, at tain. Again, fire was observed tn the No 3 engine nacelle. This time the 1305, September 8, 1948, for New Orleans, left bank of C0 hotties was dxsc.nc.rged Louisiana, via Tampa with a flight crew and all electrical sources were cut off consisting of Captain M. J. Morse, Co- by the emergency power switch The ap- pilot W. G. Leyshon and Captain Marshall proach was continued, and a landing ac- Hope, who was a third crew member. The complished at 1405. Since there was no aircraft carried 13 passengers, 1,800 hydraulic pressure to operate the right gallons of fuel and 690 pounds of cargo. brake, the stop was accomplished by the At the time of takeoff, the gross weight use of the emergency air Lottie. of the aircraft was 56,387 pounds which was within the certificated limit and Investigation properly loaded with respect to the cen- ter of gravity. Examination of the aircraft disclosed The flight progressed en route in ac- that a fire had originated in the No. 3 cordance with an instrument flight plan engine nacelle. Though the greatest at an altitude of 6,500 feet. When ap- damage was confined to the interior of proximately 75 miles southeast of Tampa, the nacelle, the wing and flap area im- at 1342, the flight was granted clearance mediately aft of the nacelle was to descend for a landing at the Tampa In- scorched and wrinkled on both top and ternational Airport. Ten minutes later, bottom sides. Sparks and pieces of when the descent had been made to 3,500 molten metal flowing from the nacelle feet, the crew observed that the fuel completely destroyed the fabric of the pressure gauge for the No. 3 engine indi- right elevator Fabric on the rign^ cated zero, the cylinder head gauge indi- side of the rudder was loose and slight- cated 265 degrees and was rising rapidly, ly scorched The entire right landing and that the oil pressure gauge indicated gear was damaged by fire The hydraulic zero. Immediately, the crew attempted to and air lines to the right landing gear feather the No. 3 propeller, but it con- were destroyed. Both right main wheel tinued to rotate slowly. Then, observing tires were burned and worn to the fabric fire in the No. 3 engine nacelle, they due to the fire and the emergency stop. closed the fire wall shutoff valves and The right outboard tire had blown out. discharged the right bank of C02 bottles The fire wall shutoff valves for the No. Into the nacelle, after which the fire 3 engine were in the off position. Both appeared to be out. At 1355, three min- C02 bottles were empty and the seals utes later, when the flight was approxi- ruptured mately 45 miles southeast of the airport, The No. 3 engine was disassembled and it was found that all parts had been *A11 tiaes referred to herein are Eastern Standard properly installed at the time of over- and toased on the 24-hour clock. haul, and the engine was in satisfactory mechanical condition The iTaintenance 15 inches wide was burned through the top and operating history of Lhe engine right side of the nacelle aft of the fire reviewed and found to be normal, At tne wall. The front wing spar in the nacelle time of the fire the engine had been was badly warped and cracked from heat. flown 1.12 hours since the last over- The engine fuel pump was removed and haul. The installation of the engine pressure checked and it was found that was completed the day of the flight and there were no leaks. Particles of hose it was test flown for a period of 10 liner inside the pump indicated that It minutes. was rotating after the inlet line had As part of the investigation, the No started to deteriorate from heat. The 3 engine nacelle was reconstructed to propeller governor was bench checked and determine the fire pattern. There was found capable of normal operation. The no fire damage or evidence of mechanical carburetor was removed for testing, but II alfuncttoning in Zone 1 The propeller the leaks were too extensive to accom- was eight degrees from the full feather plish a flow check. After disassembly ing position. The mechanism was bench of the carburetor these leaks were found checked and found to be in normal oper- to be the result of exposure to intense ating condition. heat. In Zone 2 the severest fire damage The vacuum pump was bench checked and was concentrated on the upper right side found capable of normal operation, how- of the nacelle Intense fire in this ever, the fire pattern in Zone 2 indi- area consumed the vacuum pump oil sepa- cated that the origin of the fire may rator and the magnesium starter brush have been caused by malfunctioning of housing. The fuel flow meter was se- the vacuum pump system Since a metal verely damaged. All fuel, hydraulic, slug had been found lodged in the dis- electrical and drain lines were either charge line of the vacuum pump^ a series consumed or severely burned. Many of of tests were conducted to determine the these lines showed indications of havin V effect of a restriction in the line. A been burned by a concentrated fire. partial, or complete block in the line Electrical junction boxes and transmit- resulted in pressures to 60 pounds per ters were either consumed or severely square inch and air temperatures to 1200 damaged The manifold drain line was degrees F. Under these conditions, it partially destroyed. The right side of was found that a fire or an explosion the outer cowling surrounding Zone 2 had resulted in the line. been subject to intense heat, but was not destroyed. The oil separator screen Analysis was found in the bottom of the nacelle Tracing the pattern of the fire dam- in a molten condition, A piece of molt- age showed that the fire started in Zone en metal identical in composition to 2 of the No. 3 engine nacelle in the vi- that of the oil separator screen and the cinity of the oil separator, and then vacuum pump discharge line fire wall traveled into Zone 3, either around the fitting was found in the discharge line fire wall or through the fire wall fit- between the oil separator and the fire tings after they had been burned. It wall fitting. Portions of the hose con- was in this area of the oil separator nection of the discharge line showed in- that the greatest concentration of heat dications of burning from the inside was found. Furthermore, this area con- out tained the transmitters for the oil and Fire damage in Zone 3 was also con- fuel pressure gauges and it was the drop centrated on the right side of the na- in the oil and fuel pressure gauge read celle All fuel, hydraulic and oil ings which first indicated engine trou- lines were severely burned or consumed ble. Once the fire entered Zone 3, it in this area. Electrical junction boxes was fed by the fuel and oil in lines and their conduits were either destroyed which are located in that zone. or severely burned. Many of the longi- In the area of the oil separator tudinal stringers on the right side of there are three possibilities of fire, the nacelle including the oil tank sup- the oil separator, the fuel pressure port were destroyed. The oil tank was transmitters, and the fuel flow meter. missing, and despite an intensive search Of t ese three possibilities, only one, along the flight path, it was not lo- oxi separate*, cc~ t??1 r V* cated. A Jagged hole four feet long and source of fuel The fuel flow meter and the f^el pressure I the oil separator screen and the fire transmitter contain the source of fuel wall fitting melted and flowed into tne but not ignition. Had the fire started discharge line as a result of fire, and in either the fuel flow re ter or tne fuel was not itself the cause of the fire. pressure transmitter, the ignition for i Other possible sources of the restriction the fire would be limited to the genera- dre a clogged oil separator screen due to tor, magnetos, or the exhaust system of oil or carbon deposits, a foreign object the eng ine. which may have entered the line during The generator is the sealed type and the installation of the engine, or a for this reason can be reasonably elimi- faulty check valve Since the oil sepa nated as a source of ignition Further- rator screen was reduced to a molten more, had fire started at the generator, mass, its condition could not be deter- fuel would have had to travel through mined The oil separator and the check the air intake blast tube, and this tube valve were completely consumed and most showed no signs of internal fire. The of the discharge line aft of the fire magnetos are entirely sealed Accord- wall was destroyed For the above rea- ingly, they are not considered to be a sons it was not possible to make any de- source of ignition. termination as to which of these three The exhaust system is not considered a possibilities was the cause of the re- likely source of ignition. The collector striction ring is forward of the diaphragm which Findings isolates it from Zone 2 where the fire occurred, therefore, it would be extreme- 1. The aircraft, crew and carrier were ly unlikely that fuel would be carried properly certificated. forward from Zone 2 to the collector 2. Forty-five minutes after takeoff ring. The engine exhaust stacks are lo- the fuel and oil pressure for the No. 3 cated outside of the nacelle and in this engine were reading zero, and the cylin- case too far removed from the source of der head temperature was rising rapidly fuel to be a likely source of ignition. 3. Fire was observed in the No 3 en- The one remaining possibility of fire gine nacelle, after which the No 3 pro- which contains the sources of both fuel peller was partially feathered and both and ignition is the oil separator Tests banks of C02 in the nacelle were dis- conducted, as have been previously de- charged. scribed, showed that when the discharge 4. Shortly after experiencing fire in line from the vacuum pump to the oil sep- the No. 3 engine a normal landing was ac- arator was restricted, the pressure in- complished at the Tampa Airport. side the line was sharply increased fol- 5. Greatest fire damage was in Zone 2 lowed by a like increase in temperature. in the area of the vacuum pump oil sepa- This increase in temperature and pressure rator . was sufficient to ignite or explode the 6. A restriction in the discharge line mixture of oil and air present in the oil of the vacuum pump causes increases in separator or discharge i pressure and temperature sufficient to line Therefore, the oil separator must have been the ori- Ignite the fuel-air mixture in the oil gin of the fire This conclusion is sup- separator. ported by the fact that the oil separator was completely consumed, and that the Probable Cause hose connection for the discharge line showed that it had been burnt from the The Board determines that the probable inside out cause of this accident was a fire in the The only fact not determined is the vacuum pump exhaust system due to a re- cause of the restriction in the discharge striction of an unknown origin. line or the oil separator for the vacuum pump system The slug of metal found in HY THE CIVIL AERONAUTICS BOARD the discharge line could not have been the restriction It had been melted and /s/ JOSEPH J O'COHHELL, JR was of the same material as the oil sep- Is! OSWALD RYAN arator screen and the vacuum pump dis- Isl JOSH LEE charge line fire wall fitting. It ap- Isl HAROLD A JONES pears, therefore, tha^s this material from Isl RUSSELL B ADAMS Supplemental Data Investigation and Hearing employed by National Airlines February The Civil Aeronautics Board was noti- 5, 1948, and at the time of the accident fled of the accident September 8 1948, had logged approximately 6,000 flying by National Airlines at Miami, Florida* hours, of which 829 were accumulated in An investigation was immediately initi- four-engine equipment. W. G. Leyshon, ated in accordance with the provisions copilot, possessed a valid airline of Section 702 (a) (2) of the Civil Aero- transport pilot rating. He was employed nautics Act of 1938, as amended. Public by National Airlines July 15, 1948, and hearing was held in two parts, first at the time of the accident had logged being held m Tampa, Florida, September approximately 9,800 hours, of which 217 30, 1948, and the second being held in had been obtained in four-engine equip- Miami, Florida, December 15, 1948. ment. Air Carrier The Aircraft National Airlines, Inc., a Florida Corporation, with headquarters in Miami, NC-33682, a DC-4 aircraft, currently certificated by the Civil Aeronautics Florida, is a holder of a certificate of Administration, was owned and operated public convenience and necessity awarded by National Airlines. It had a total of by the Civil Aeronautics Board, which 7,740 flying hours, of which 598 had authorized the company to conduct flight been accumulated since the last major operations between Miami, Florida, and overhaul. It was equipped with four New Orleans, Louisiana, via Tampa, Pratt and Whitney R-2000-D3 engines. Florida. The No 3 engine had a total of 3,918 Flight Personnel hours, and had accumulated one hour and 12 minutes since overhaul, The aircraft Captain M. J# Morse possessed a valid was equipped with Hamilton Standard Pro- airline transport pilot rating* He was peIlers Model 23E50-505. ---15047 (i) CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: October 19, 1951 Released: October 26, 1961 NATIONAL AIRLINES, INC.---PH ILADELPHIA INTERNATIONAL AIRPORT, PHILADELPHIA, PENNSYLVANIA, JANUARY !US 1951 THE ACCIDENT feet, overcast, wind south-southwest at four At 14131 January 14, 1Q51, a Douglas DC-4, miles per hour, and visibility 1 1/2 miles, N-74685, owned and operated by National Air- with light snow and smoke Flight 83 was lines, Inc , crashed and burned following an cleared by the New York Air Route Traffic overshot landing ac the Philadelphia Inter- Control to proceed to North Philadelphia national Airport, Philadelphia, Pennsylvania. range station via Amber Airway No 7, to Aboard were twenty-five passengers, including maintain 4,000 feet, with Newark designated three infants, and a crew of three. Six as the alternate airport. passengers and one crew member lost their Thirteen minutes after takeoff, at 1346, lives and the aircraft was substantially Air Route Traffic Control issued the flight destroyed by impact and fire a new clearance to proceed to the Philadel- phia ILS outer marker, to maintain 4,000 HISTORY OF THE FLIGHT feet, and to contact Philadelphia Approach National Airlines* Flight 83 departed Control when passing the Northeast Philadel- Newark, New Jersey, at 1333, January 14, phia range station. At 1354 the flight re- 1951, for Norfolk, Virginia, with a scheduled ported over Northeast Philadelphia at 4,000 stop at Philadelphia. The crew consisted of feet and was cle ared by Approach Control to Captain Howell C Barwick, Copilot Edward J descend, crossing the Philadelphia range Zatarain, and Stewardess Mary Frances station at 3,000 feet, and to advise the Housley The aircrafts total weight at tower when leaving the 4,000- and 3,COO-foot takeoff was 58,601 pounds, which was within levels. It was also advised that the alti- the allowable gross takeoff weight of 64,211 tude was unrestricted after passing the pounds, the load was properly distributed range station, and that it was cleared to Flight 83 was scheduled to leave Newark at make a straight-in approach to Runway $ 1300, but was delayed 33 minutes due to the With the above clearance, local weather was replacement of a malfunctioning generator given precipitation ceiling 500 feet, sky Hie company flight clearance was filed at obscured, visibility 1 1/4 miles, snow and 1215 for the scheduled departure at 1300, and smoke, and wind south-southwest two miles this clearance was also used for the delayed per hour. Following this clearance, the departure. Attached to it was the weather flight descended and reported over the information for the flight, and a notice that Philadelphia range station at 3,000 feet, the ILS (instrument landing system) glide path was again cleared for an approach to Runway at Philadelphia was inoperative until further 9, and was advised to report leaving notice Immediately before taking off, the thousand-foot levels The flight acknowl- pilot requested and received from the tower edged and reported leaving 3,000 feet at the latest Philadelphia weather (reported on 1404, but no report of leaving 2,000 feet the 1328 CAA teletype sequence report and was received by Approach Control According received at Newark after he boarded the air- to the captain, they then proceeded to the craft), which was ceiling measured 1,000 outer marker and executed a procedure turn At 1408 the flight reported over the outer marker, inbound, and stated that it ^All times referred to herein are Eastern was at 1,600 feet and descending A dear- Standard based on the 24-hour clock ance was immediately reissued to land on Comm---DC---38568 (1) Runway 9, and the wind was given as south- heavy wire boundary fence seven feet high southwest, three miles per hour The flight runs lengthwise through the center of the was advised that the glide path was mopera- ditch Adjacent to the ditch to the east is tive, that the frequency of the ILS localizer a road Wien the aircraft struck the ditch was 110 3 me, that a 2,000-foot extension to a large portion of the fence was torn down the west end of the runway was under con- and the aircraft came to rest with its nose struction, and that braking action on Runway resting m the road The rear section of 9 was poor-to-fair According to tower per- the fuselage remained suspended with the sonnel this transmission was acknowledged sill of the main cabin door six to eight The crew, however, stated that they did not feet above the east bank of the ditch Fire 9 originated in the vicinity of the No 2 and receive it The flight continued its approach past No 3 engine nacelles and rapidly spread the middle marker to the airport, and was rearward, substantially destroying a la ge first observed by ground witnesses beneath portion of the aircraft the overcast and directly over the inter- The nose wheel assembly was separated section of Runways 4/22 and 0/27, located from its fastenings by the impact, and the approximately 1,200 feet east of the thres- nose gear strut was severed just above the hold of Runway Q Although the aircraft was fork The lower portion of this strut, first seen beneath the overcast and within which contained the axle and wheel, was the boundaries of the airport, the crew' found on the ground near the aircraft, the stated that they became contact at an alti- tire had been completely consumed by fire tude of approximately 500 feet, between the Both of the main landing gear struts were outer and middle markers. bent rearward and had pulled loose from The aircraft was next seen to descend their respective fittings on the mam spar steeply, flare out for a landing in a normal Heat caused three of the main gear tires to manner, and float a considerable distance blow out, the outboard tire on the right After making contact with the runway the side was not badly damaged, and still re- aircraft continued straight ahead, passed tained air The main landing gear wheels beyond the end of the runway, and crashed and brake assemblies were subsequently re- into a ditch at the east boundary of the moved and tested They were found capable airport. Fire immediately followed Seven of normal operation of the twenty-eight occupants did not evacu- Both wings of the aircraft were exten- ate the aircraft, and were fatally burned. sively burned from the fuselage to the out- The airport fire-fighting equipment was board wing panels. Approximately one-half dispatched immediately to the scene, but of the left wing flap and a portion of the efforts to extinguish the fire and rescue right wing flap were damaged The fabric of the remaining occupants were futile the left aileron was completely burned off, the right aileron was undamaged The mte- INVESTIGATION gral wing gas tanks were ruptured at a point Investigation disclosed that the aircraft adjacent to the main landing gear fittings had traveled a distance of 243 feet from the The extreme forward portion of the nose end of the runway before striking the ditch section of the fuselage escaped damage, the Ekinng this portion of the ground roll it pilots cockpit was almost completely de- struck and damaged a floodlight attached to stroyed All instruments m the cockpit a concrete stanchion The ditch, approxi- were damaged and rendered unreadable The mately 30 feet wide at the point of impact, emergency air brake bottle had been dis- varies in depth from 7 1/2 feet on its west charged Both CO} fire extinguisher bottles side to 5 1/2 feet on the east side. A used to extinguish fires in the baggage compartment or engine nacelles were fully 9 charged The selector valves and cylinder The recorded transmissions in the tower showed valves used in discharging these bottles that all the above messages were transmitted to the flight This automatic recorder does not re- had not been pulled cord transmissions from aircraft to tower The fuselage from the cockpit 3 The outer marker and the middle marker are rearward to the bulkhead behind the 5 66 andO 66 miles respectively from the approach end of the runway lavatory was almost completely consumed The tail section of the aircraft was undam- wet snow Adjacent to the runway, on both aged sides a id extending throughout its entire All four engines were badlv damaged The length, were two rows of high-intensity run- nacelle and a propeller blade of the No 1 way (Bartow) lights, spaced 200 feet apart engine propeller were damaged by contact These are standard white lights except that ftith the floodlight The blades oi all pro- the final 1,506 feet tie amber The tower pellers were bent rearward, and it was controller on duty stated that the runway determined that little or no power was being lights were lighted and that the selector developed at the time of impact There was switch was at the position of highest inten- no evidence of mechanical malfunctioning of sity The day of the accident, portable either the aircraft or engines prior to the green threshold lights with yellow cone-like accident bases divided the mam 5,2?0-foot runway Wheel marks showed that initial contact from the 2,000-foot extension under con- was made by the aircrafts main landing gear struction at the approach end wheels 3,140 feet down the runway and that A row of red neon approach lights, located the nose wheel touched down 52? feet farther to the left of the runway extension, extend- on The remaining distances of surfaced ed in a westerly direction a distance of runway from these observed touchdown points 1,500 feet from the west end of the thres- are 2,140 and 1,612 feet, respectively For hold of Runway 9/27 These approach lights the remainder of the runway, marks made by are actuated by an automatic device situated the main tires were not continuous Wheel near the west end of the runway and con- marks also appeared on the turf from the end trolled by a photoelectric cell This cell of the runway to the ditch There was evi- is pointed in a northerly direction and dence that the tires had slid m several depressed at an approximate angle of 25 de- places grees, actuating the lights when illumina- Information in the companys required tion equals 30-foot candles, and turning Operations Manual for CC-4s a copy of which them off when this value increases to 50- was on board the aircraft, indicated that foot candles Snow coverage does not the landing distance required to come to a appreciably affect its operation The tower full stop from a 50-foot height on a dry operator stated that he presumed the ap- runway is 2,550 feet Also, that under un- proach lights were on Under conditions of suitable runway conditions (wet or icy, etc ), restricted visibility the lights cannot be or with malfunctioning brakes, a total run- seen from the tower because a reflector way length of 4,250 feet is required These attached to each li^ht concentrates the distances are predicated on flight tests light beam toward approaching aircraft If under conditions similar to those encountered the photoelectric cell is operating properly, by the subject aircraft. Captain Barwick the lights cannot be manually turned on or testified that only 1,550 feet were required off from the tower, this can be done only if to stop the DC-4 on a dry runway the system fails Subsequent to the acci- Following tests, the Douglas Aircraft dent the approach light mechanism was tested Company published, on November 4, 1946, as and found normal The flight crew stated part of the 1X3-4 Manual, information thac a that they did not see the approach lights distance of 1,936 feet is required to bring The work on the 2,000-foot extension to this type aircraft to a full stop from point the west end of the runway was nearing of touchdown, providing there is normal completion the dav of the accident. No braking action and a dry paved surface is construction work was being performed that used In the event of wet or slippery run- day, and there were no obstructions to air- ways the distance required is increased, and craft landing on Bunway 9/27 will vary from 3,650 to 5,283 feet According to the captain the fbight to Runway 9/27 is 5,280 feet long and is the Philadelphia was routine and he was cogni- ILS runway It was surfaced with a black zant of the lowering weather conditions He tar-like composition, and a large portion of said that even though he did not receive the the east end was covered with fine gravel last transmission from the tower (advising At the time of the accident the runway was that the glide path was inoperative, etc also covered with approximately 3/4 inch of it made but little difference as he was advised of most of this information through in January 1951 he was sent to the company's published NOTAMs that he could see the base at Miami, Florida, for additional lighted runway throughout its entire length training on DC-4s, receiving 24 hours of He stated that he purposely made a normal but ground school and six hours and thirty slightly high approach to avoid possible minutes of flight training On January 13, landing hazards, that he intended to land 1951, the day before the accident, as part within the first third of the runway and that of his requalification he was given a com- there were no obstructions to his vision pany line check between Jacksonville, The aircrafts windshield wipers were working Florida, and Newark This check consisted properly After touchdown he considered of flying the DC-4 as captain, under the there was sufficient distance remaining with- supervision of a company check pilot, on in which to stop and therefore did not Nationals scheduled Flight 50 over the attempt to go around As soon as the nose route mentioned. Stops were made at wheel made contact with the runway, he began Charleston, South Carolina, Wilmington, applying brakes. Although there seemed to North Carolina, Richmond, Virginia, Washing- be adequate brake pressure, there was ap- ton, D C , Baltimore, Maryland, and Newark parently no effective brake action, the No stop was scheduled at Philadelphia His aircraft continuing ahead with little decel- last previous landing at the Philadelphia eration When approximately 1,000 feet from International Airport was made on April 30, the end of the runway the emergency air 1950, with a Lodestar brakes were applied with no apparent retar- In accordance with the companys policy, dation Flight 83 which departed Newark was dis- Tlie crew said that an external fire and patched from the companys office at New another between the pilots compartment and York International Airport This is accom- the main cabin door started immediately plished by teletype and telephone through after impact The engine switches and elec- the New York dispatcher, who delegates the trical system switches, etc , were not turned authority to a company agent Heather in- off and the interconrounication system between f ox mation is available to crews at Newark, the pilots compartment and the main cabin and NOTAMs are put on the bulletin board was not used Pertinent information necessary to the suc- One pilot escaped through the front cargo cessful completion of the flight is attached door, the other through the sliding cockpit to the flight clearance window Their attempts to assist the stewardess, still in the cabin, with the ANALYSIS evacuation of the passengers were unsuccessful Captain Barwick stated that the flight due to the intense heat already existing m was routine until the final approach was the area of the main cabin exit which pre- made to the Philadelphia International Air- vented them from getting close to it The port He also said that he did not receive stewardess, who opened the main cabin door, the final radio transmission from the tower, advised everyone to remain calm and rendered which included the runway and braking condi- the utmost assistance to all, was highly tions, the ILf> localizer frequency, the fact praised by the passengers who escaped, for that the glide path was inoperative, and the her courageous efforts The emergency rope general field conditions It is difficult ladder achored near the mam cabin door was to understand why this transmission was not not used, nor were any of the cabin emergency received by the flight since it was estab- exits opened lished (by means of automatic recorder in Captain Barwick stated that he qualified the tower) that it was transmitted as as captain on DC-4 aircraft on September 26, stated, and since all other messages to the 1947, and that he had flown this equipment as flight were received and acknowledged It captain approximately 22 hours The greater is probable, however, that had this informa- part of this flving experience was m 1947, tion been given to the flight when it first and he did not again fly DC-4s as captain contacted Approach Control over Northeast until January 1951 In the interim he had Philadelphia, the additional time allowed flown either as copilot on FC-4s or as cap- would have permitted the captain to make a tain or copilot on Lockheed Lodestars Early better evaluation of the field conditions, ---38568 particularly since this was his first land- program of this air carrier, there would ing on the airport m several months The still appear to have been rocm for further fact that the ILS glide path was inoperative improvement at the time of this accident should not have had any bearing on the ap- Subsequent to the accident, a committee proach to the runway since this facility was comprising both company personnel and mem- not needed to effect a safe landing Also, bers of the Air Line Pilots Association was when the approach was made there were no formed, and they recommended the following hazardous obstructions to the approach end training for Captain Barwick which was of the runway or anything to seriously adopted by National a weeks rest with hinder the pilots vision Therefore, if pay, a short familiarization ride with a the approach had been properly planned, the company check pilot, 30 days or 85 hours as aircraft could have been stopped by landing copilot, this time to be divided equally on the first third of the old runway If we between two captains, two round trips on the accept the captains testimony that he be- line with different check pilots, and a CAA came contact at an altitude of 50 i feet in physical examination If the above was the vicinity of the middle marker and that completed in a satisfactory manner, he was as he approached the runway he could see the to be returned to the line as captain. green threshold lights and all of the runway As a result, Captain Barwick received the lights, there is even less excuse for his following training* 98 hours and 43 minutes landing so far down the runway, particularly as copilot, of which 17 hours and 4G minutes with a negligible wind His decision to were flown under instrument flight condi- is-'d at a point, which even under favorable tions, and 12 hours and 50 minutes of check coitions would be considered marginal to time Captain Barwick received passing azlow stopping, does not reflect the judg- grades and was then returned to the line as nent and "highest degree of care which the captain public js entitled to have exercised b> the In addition to the above, the company re- airline pilots m whose hands their safety viewed its training program with particular rests emphasis to emergency "pull up" procedures While we recognize that the pilot was The Board is of the opinion that Mary required to make a quick decision as between Frances Housley, the stewardess, acted in a landing and making an emergency "pull up", most courageous manner, and that she lost the correct decision could have been made her life because of her high sense of duty more probable by additional training m attempting to evacuate the passengers A review of the pilot training given Captain Barwick prior to the accident indi- FINDINGS cates that he received 24 hours of ground school training and passing grades on six Qi the basis of all available evidence, hours and 30 minutes of DC-4 flight that Board finds that training He also was given a company route 1 The carrier, the aircraft, and the check between Jacksonville and New York by crew were properly certificated. the assistant chief pilot the day before the 2 The flight was properly dispatched accident and rated as satisfactory Although 3 The runway was covered with wet snow the training program complied with the mini- and braking conditions were poor-to-Fair mums specifically set forth m Section 4 The landing was made too far down the 61 132 of the Civil Air Regulations, it is slippery runway to permit stopping within also the duty of the air carrier to provide its limits sufficient training to insure that the pilot is competent m view of all the circum- PROBABLE CAUSE stances No rule can be promulgated which will provide for all contingencies and it is The Board determines that the probable in the area not specifically covered by the cause of this accident was the captains minimum standards that the training of error m judgment in landing the aircraft pilots must be solely in the hands of the air too far down the slippery runway instead of carrier We have on several occasions been executing a missed approach procedure called upon to question and to examine the BY THE CIVIL AERONAUTICS BOARD training program of this carrier Marked progress has already been made and the air /$/ Donald W Nyrop carrier must be given full credit for this /s/ Oswald Ryan improvement But the price of safety is /s/ Josh Lee "eternal vigilance, and despite the prog- /s/ Joseph P. Mams ress already attained in the training /s/ Chan Gurney ---36568 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 Supplemental Data INVESTIGATION AND HEARING through Philadelphia, Pennsylvania, o Baltimore, Maryland, Washington, D C , and The Civil Aeronautics Board was notified Richmond, Virginia, to Norfolk, Virginia promptly after the accident by CAA Communi- cations An investigation was begun immedi- FLIGHT PERSONNEL ately in accordance with the provisions of Captain Barwick, age 37, held a currently Section 702 (a)(2) of the Civil Aeronautics effective airman certificate with airline Act of 138, as amended A public hearing transport and flight instructor ratings He was ordered by the Board and was held m had accumulated a total of 6,723 flying Philadelphia, Pennsylvania, January 31, hours, of which 191 hours were on DC-4 type February 1, and 2, 1951 equipment. His last CAA medical examination was October 26, 1950, and his last instru- AIR CARRIER ment check was January 10, 1951 Copilot National Airlines, Inc , is a Florida Zatarain, age 30, also held a currently ef- corporation with general offices m Miami, fective airman certificate with an airline Florida, and operates as an air carrier transport rating. He had accumulated 4,214 under currently effective certificates of flying hours, of which 158 were on DC-4 type public convenience and necessity issued by equipment. His last CAA physical examina- the Civil Aeronautics Board, and an air ear- tion was May 5, 1950. ner operating certificate issued by the Civil Aeronautics Administration. These THE AIRCRAFT certificates authorize the company to trans- N-74685, a Douglas aircraft, model DC-4- port by air, persons, property and mail over 1009, was manufactured January 22, 1947 It various routes within the continental limits was equipped with four Pratt and Whitney of the United States and Havana, Cuba, in- model R-2000-D-3 engines and Hamilton Stand- cluding the route from Newark, New Jersey, ard hydromatic propellers ---38568 CIVIL AERONAUT ICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: July 23, 1948 Released: July 28, 1948 NORTHWEST AIRLINES, INC.---MT. SANFORD, ALASKA---MARCH 12, 1948 The Accident radio range station, 159 miles, 34 de- A Northwest Airlines Dougla^ DC-4, grees, from Anchorage, and at this time NC-95422, Flight 4422, a non-scheduled it estimated that it would be over North- way, Alaska, 283 miles from Anchorage, at charter flight en route from Lunghwa Air- 2136. Gulkana did not establish communi- port, Shangh^x, China, to La Guardia cation with the flight. However, the Field, New York, crashed on the west slope of Mt. Sanford, Alaska, at an alti- flight repeated its clearance into the tude of 11,000 feet at approximately Fairbanks area back to Northway, Indi- 2114,1 March 12, 1948. The 24 passengers cating that the flight could receive on and 6 crew members were fatally injured, 400 kcs, the frequencies for both the and the aircraft was demolished by impact Northway radio range and communication. and fire.. Shortly before the position report of 2103, the flight was observed flying an History of the Flight easterly heading approximately 4 miles south of the Gulkana radio range station. The flight from Shanghai to Anchorage, Approximately 42 miles, 51 degrees, Alaska, was routine. At Anchorage a new from the Gulkana radio range station is crew consisting of Captain J. G. Van Mt. Sanford, the elevation of which is Cleef, Captain R. G. Petry, First Officer 16,208 feet. In order to provide a safe J. J. Stickel, Navigator W. W. Worsley, lateral distance from Mt. Sanford for Flight Mechanic D, L. Rector, and Purser aircraft flying the route, the airway R. J. Haslett took over with Captain Pe- from Gulkana east is deflected to the try occupying the pilots seat at the north, its course being 23 degrees. Fif- time of departure from Anchorage. teen minutes after the flight was ob- Twenty-four passengers for whom the served flying easterly from Gulkana a flight had been chartered fro: 11 Shanghai fire was observed on the western slope of to New York, New York, were aboard. Mt. Sanford. Except for a repeat trans- Take-off from Anchorage was accom- mission of the flights Gulkana position plished at 2012, March 12, 1948, and the report, overheard by Northway Radio 124 flight proceeded en route.2 At 2028 the miles northeast of Gulkana and approxi- flight reported Over the Wasilla Intersection, mately one minute before the fire was ob- which is the intersection of the north course of served on Mt. Sanford, no communication the Anchorage radio rapge and tne east course was received from the flight after 2103. of the Skwentna radio range. This inter- Northwest Airlines, at 2150, requested section is located 35 miles north5 of from Anchorage Radio the reported time of Anchorage. Three minutes later, at 2031, the flight over Northway, at which time the flight reported that It was at its Anchorage Radio advised that neither the cruising altitude of 11,000 feet. At Northway nor the Gulkana stations had 2042 the flight reported over Sheep Moun- been able to contact the flight, and that tain, a non-directional radio beacon lo- a fire had been reported on Mt. Sanford. cated 85 miles airways distance, 31 de- Radio facilities over the route were im- grees, from Anchorage. At 2103 the mediately alerted. Since all attempts to flight reported being over the Gulkana contact the flight were unsuccessful, it was concluded that the flight had struck 1 All times referred to in this report are Alaskan Mt. Sanford and burned. Standard and based on the 24-hour clock. 2See Appendix I---Chart of Airway. Investigation 3All bearings and courses as stated in this report are magnetic. Average magnetic variation for the Immediately after the fire was re- route which was flown is 29 degrees east. All mile- age is given In statute miles. ported, the Gulkana and Northway radio ---19752 (1) z ranges and the Sheep Mountain radio bea- able to see the Northwest Airlines1 in- con were ground checked and found normal. signia on the vertical fin. A pilot and observer, at 2330, two Mt. Sanford, elevation 16,208 feet, is hours end 15 minutes after rhe fire was the most northerly peak of the Wrangell observed on Mt- Sanford, took off froi ii Mountains which are located in the south- the Gulkana Airport in a Luscombe air eastern portion of interior Alaska. plane to Investigate. This aircraft flew Twenty miles to the southwest of Mt. San- at an altitude of 10,000 feet in the Mt. | ford is Mt. Drum which has an elevation Sanford vicinity but observed no sign of of 12,002 feet. This entire area is ex- fire or wreckage. The pilot reported tremely precipitous, and to a large ex- that the ceiling was unlimited and the tent is covered by snow and ice to a visibility 50 miles except when occasion- depth of 60 to 200 feet. As stated ally reduced in the vicinity of Mt. San- above, the airway from Gulkana east is ford by a display of the aurora borealis. deflected to the north so that aircraft According to this pilot, the northern flying the route will be provided safe lights appeared as hanging curtains and lateral clearance from these mountains* were unusually bright, obscuring Mt. San- Snag, in the Territory of the Yukon, ford from view for periods of one to five Canada, is located 170 milds east of Gul- minutes. However, he stated that neither kana. It is about one-third the distance radio reception nor compass was affected, from Anchorage to Edmonton, Alberta, Can- and that the Gulkana radio range operated ada, which is a fuel stop for Northwest normally. Airlines used on their route from Anchor- The United States Air Force, 10th Res- age to Minneapolis, Minnesota. An air- cue Group based at Anchorage, routed an craft en route to Edmonton could fly aircraft to Mt. Sanford three hours after directly from Gulkana to Snag except that the fire had been reported. The pilot Mt. Sanford is located on this straight saw no sign of fire, and reported radio line course. tApproximately 18 miles reception and magnetic compass operation would be saved by flyi-ng this direct normal. route from Gulkana to Snag, and given un- At 0600 the day following the acci- restricted visibility, Mt. Sanford could dent, a DC-3 with officials from the Civ- be safely circumnavigated. il Aeronautics Board, Civil Aeronautics Captain J. G. Van Cleef was employed Administration, and Northwest Airlines by Northwest Airlines June 27, 1942, and departed from Anchorage for the Mt. San- his employment was continuous until the ford area. The west course of the Gul- accident. He held a valid airline trans- kana radio range and the Sheep Mountain port pilot rating, and had logged a total radio beacon were flight checked en route of 4,453 flying hours, of which 733 were and found to be operating normally. The obtained in DC-4 aircraft and 665 hours wreckage was located at an elevation of of which were flown in foreign opera- 8,500 feet on the west slope of Mt. San- tions. During the war he had been as- ford 23 miles southeast of the center signed to the Army contract operation line of the airway. The point of impact, conducted by Northwest Airlines in Alas- approximately 2,500 feet above the wreck- ka, and had made numerous flights over age, was observed to be a section of tne Anchorage-Edmonton segment. Since smoke-blackened snow and ice- From this the war he had wade 21 flights over this point tnere was a clearly defined fire- route as a captain for Northwest Air- path where the burning wreckage had fal- lines. len down the almost perpendicular wall of Captain R. G. Petry was employed by the mountain. Northwest Airlines September 9 1942, and The wreckage was in a small glacial his employment was continuous until the cirque the walls of which were avalanche accident. He held a valid airline trans- slopes. Snow and ice were constantly port pilot rating, and had logged a total falling into this cirque from an over- of 8,324 flying hours , of which 728 were hanging glacier 4,000 feet above. It was obtained in DC-4 equipment and 607 hours estimated that the falling snow and ice of which were flown in foreign opera- would cover the wreckage in a matter of tions. During the war he made many days. The scene of the accident was in- flights over this route for the Army and accessible from either the ground or the was making his 24th trip for Northwest air. However, positive identification Airlines at the time of the accident. was made by an Air Force pilot who was First Officer J. J. Stickel was employed by Northwest Airlines May 3, 1944. and Since the aircraft was observed to fly his employment had been continuous until easterly from Gulkana, at which time it the accident. He held a valid airline was 4 miles south of the Gulkana radio transport pilot rating, and had logged a range station, it appears that the flight total of 4,772 flying hours, of which 779 was not following the airway, but was had been obtained in DC-4 aircraft, and flying directly from Gulkana to Snag, It 661 hours of which were in foreign opera- is probable that the pilot, relying on tions. He had also been assigned to the good visibility, felt confident that he Army contract operation conducted by would see Mt. Sanford and be able to Northwest Airlines in Alaska during tne safely circumnavigate it. Though no war, and had made numerous flights oyer clouds were reported, the top of Mt. San- this route. ford could very well have been capped by The weather forecast for the flight, a thin layer of clouds, Such a layer of prepared at 1820 March 12, 1948. antici- clouds would not only have tended to ob- pated excellent visibility and unlimited scure the mountain but may have acted as ceilings from Anchorage to Snag. Wind a reflector for the aurora borealis which at 11,000 feet was indicated at Anchorage was observed to be particularly brilliant to be from 245 degrees at 10 miles per the night of this flight. hour, at Gulkana from 275 degrees at 22 It is concluded, therefore, that the miles per hour, and at Northway from 285 flight flew south of the airways for the degrees at 28 miles per hour. A thin purpose of flying the straight line veil of clouds over Mt< Sanford above course from Gulkana to Snag, intending to 10,000 feet could have been present at circumnavigate Mt. Sanford; and since Mt. the time of tnis flight, but none was re- Sanford was not discernible eitner be- ported by the ground stations between An- cause of clouds, the aurora borealis, or chorage and Northway. There was not suf- both, the aircraft crashed into the moun- ficient moisture m the air to cause ap- tain. preciable aircraft icing. The air was stable, but light mechanical turbulence Findings existed over the mountains. The moon set On the basis of all available evi- March 12 at 2012. dence, the Board finds that: Discussion 1. The carrier, aircraft, and crew were properly certificated. Communications from the flight were 2 The flight departed from Anchorage received to within approximately one min- at approximately 2012, March 12 , 1948, ute before the crash. In view of the and proceeded toward Edmonton, Alberta fact that no mechanical difficulty was Canada, at a cruising altitude of 11,000 reported at any time it is unlikely that feet. this accident was caused by any mechani- 3. Routine position reports were re- cal failure. Furthermore, the aircraft ceived from the flight until after it had crashed at its cruising altitude of passed the Gulkana radio range station, 11,000 feet. All ground radio navigation which was 159 miles 34 degrees magnetic facilities were flight checked and found from Anchorage. to be operating normally, so they also 4. The aircraft was observed approxi- are eliminated from any causal relation- mately 4 miles south of the Gulkana radio ship to the accident. range station at approximately 2100 fly- The possibility that an error in navi- ing an easterly course. gation was made as a result of an errone- 5. Celling and visibility over the ous compass reading caused by the aurora route were reported as unlimited, though borealis cannot be supported. Had the conditions were suitable for the forma- pilot followed airways he would have re- tion of a thin veil of clouds over the mained on or reasonably close to the tops of mountains in the area. northeast course of the Gulkana radio 6. At the time that the flight was in range, which was operating normally, re- the Gulkana area a brilliant display of gardless of magnetic compass reading. the aurora borealis was observed. Furthermore, other pilots flying shortly 7 The airway east from Gulkana is de- after the accident in the same vicinity flected to the north so as to provide a and under the same conditions reported no safe lateral distance from Mt. Sanford, noticeable effect of the aurora borealis 16,208 feet In elevation, for aircraft on the magnetic compass. flying the route. fl* 8- The aircraft crashed approximately probably obscured by clouds or the aurora 42 miles 51 degrees from the Gulkana ra- borealis or both while flying a course dio range station on Mt- Sanford at its off the airway. cruising altitude of 11,000 feet, and 23 miles southeast of the center line of the BY THE CIVIL AERONAUTICS BOARD airway as described above. Isl JOSEPH J. 0 'CONHELL, JR. Probable Cause Is/ OSWALD RYAN Isl HAROLD A. JONES The Board determines that the probable /s'' RUSSELL B. ADAMS cause of this accident was the pilot !s failure to see Mt. Sanford, which was Lee, Member, did not participate. --- 19752 Supplemental Data Investigation his employment was continuous until the The Civil Aeronautics Board, VIII Re- accident. He held a valid airline trans- gion, was notified of the accident at port pilot rating, certificate #65884, 2145, March 12, 1948, by a telephone call and had logged a total of 8,324 flying from Civil Aeronautics Administration hours, of which 728 were obtained in DC-4 communications An investigation was equipment and 607 hours of which were initiated immediately in accordance with flown in foreign operations. During the the provisions of Section 702 (a; (2) of war he made many flights over this route Civil Aeronautics Act of 193 8, as amend- for the Army and was making his 24th trip ed. The investigator from the Civil for Northwest Airlines at the time of the Aeronautics Boards regional office ar- accident. rived at approximately 0700 March 13, First Officer J. J. Stickel was em- 1918, at Mt. Sanford by air, after which ployed by Northwest Airlines May 3, 1944, the wreckage was located from the air. A and his employment had been continuous public hearing was conducted as a part of until the accident. He held a valid air- this investigation in Minneapolis, Minne- line transport pilot rating, certificate sota, April 16, 1948. #49340, and had logged a total of 4,772 flying hours, of which 779 had been ob- Air Carrier tained in DC-4 aircraft, and 661 of which were in foreign operations. He had also Northwest Airlines, Inc. is incorpo- been assigned to the Army contract opera- rated in the State of Minnesota, and tion conducted by Northwest Airlines in maintains its Headquarters at St. Paul, Alaska during the war, and had made nu- Minnesota. At the time of rhe accident, merous flights over this route. it was operating under a certificate of Wayne W. Worsley, navigator, had been public convenience and necessity and an employed by Northwest Airlines since No- air carrier operating certificate, both vember 25, 1946. He held a flight navi- issued pursuant to the provisions of the gator certificate dated September 29, Civil Aeronautics Act of 1938, as amend- 1947, and had logged 2,556 flight hours. ed. The certificates authorized the com- Donald L. Rector, flight mechanic, had pany to transport persons, property, and been employed by Northwest Airlines since mail, and schedule their commerce be- October 18, 1939. He held A and E li- tween various points in the United cense #384837 issued July 5, 1945. Rob States, Alaska, and the Orient. ert J. Haslett, flight purser, had been Flight Personnel employed by Northwest Airlines since Oc tober 11, 1945. Captain J. G. Van Cleef wa$ employed by Northwest Airlines June 27, 1942, and Ai rcraft his employment was continuous until the accident. He held a valid airline trans- The Douglas DC-4, NC-95422, Serial No port pilot rating, certificate #47178-40, 35966, Model C54-G, had been operated a and had logged a total of 4,453 flying total of 3,306 hours since its manufac- hours j of which 733 were obtained in DC-4 ture June 30, 1945. It had installed aircraft and 665 hours of which were four Pratt & Whitney R-2000-13 engines, flown in foreign operations. During the and was equipped with Hamilton standard war he had been assigned to the Army con--- hydromatic propellers, hub model 23250- tract operation conducted by Northwest 505, blade model 6507-A-0* Airlines in Alaska, and had made numerous At time of take off from Anchorage the flights over the Anenorage-Edmonton seg- total weight of the aircraft was less ment. Since the war he had made 21 flights over than the maximum allowable gross and the this route as a captain for Northwest Airlines. load was distributed with respect to the Captain R. G. Petry was employed by center of gravity within the allowable Northwest Airlines September 9, 1942, and limits. --- 19752 (I) AppENp*X DOCKET NO. 168 CHART OF AIRWAY FROM ANCHORAGE TO SNAG NORTHWAY RADIO TO EDMONTON MT. SANFORD ife,20a ^1. GULKANA RADIO MT. DRUM 13,002. SHEEP MOUNTAIN RADIO BEACON ^W?UCftflW * a CENTER LINE OF AIRWAY DIRECT COURSE GULKANA T SNAG Point "a" AIRCRAFT OBSERVED FlMlMG to ya Easterly from this point. Mr APPROXIMATE POINT OF CONTACT. POINT % - PROBABLE COURSE OF AIRCRAFT, ^HCMORAGE RADIO MAGNETIC NORTH ALU COURSES MAGNETIC AVERAGE VARATlON H9 a E. Obtaine^^rgyc^ire^latien^Qfn.igft^QiJr selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com CIVIL AERONAUTICS BOARD >.CCIDhlT INVESTIGATION REPORT Adopted1 July 7j 1949 Released, July 7 a -94C; NORTHNbST AIRLINES, INC. - fEAR EDnONTON, CANADA - OCTOBER 27, 1948 Northwest Airlines' Flight 6427, a DC-4, NC-8S7S5, en route from irneapolis, Minnesota, to Tokyo, Japan, crashed and burned about 30 miles northwest of Edmonton, Canada, October 27, 1948, with resultant death to phe captain and flight engineer. The first officer, radio operator, and navigator were seriously injured and the aircraft was destroyed by impact and subsequent fir Flight 6427 had departed Minneapolis at 1002NSTJ and arrived at Edmonton at 1530 on the first leg of a special cargo trip to Tokyo. The aircraft was serviced, and at 163? a takeoff was made for Anchorage, Alaska on an IFR flight plan. On board were Captain Benjamin W. Christian, First Officer Harry C. Upiham, Flight engineer Henry Kryzak, navigator Harold N, Learned, and Radio Operator Nicholas Tangredi. With the exception of Mr. Tangredi, who cane with the flight from Minneapolis, all crew members boarded the airplane at Edmonton. The total takeoff weight was 63,917 pounds, which was well within the allowable maximum of 70,600 pounds. No passengers were carried. Ceiling and visibility were unlimited First Officer Upham made the takeoff, and shortly after the airplane became airborne Captain Christian cut the left outboard engine and feathered the propeller, creating a simulated engine failure on taxeoff. The purpos was to instruct the first officer m emergency procedures. The airplane *A11 times referred to herein are Mountain Standard and based on the 24-hour clock. climbed very slowly and, veering slightly to the 16ft, passed over the center of Edmonton at an altitude of 400 to 500 feet. Then the flight turned to the right approximately 180 degrees to get on course toward Anchorage, This brought it back over town and Captain Christian unfeathered the propeller. Power was restored to left outboard engine and the airplane continued to climb. During this interval the tower asked the crew if they nad taken off on three engines and received a negative reply. At 1645 Trans-Canada Airlines Communications received the following message from Flight 6427, "We were off at 32, cruising 7000 at 44, esti mating Whitecourt at 02, out (from the ramp) at 22." No indication of trouble was given and no further messages were received from the flight. Although this message indicates the flight had reached its assigned cruising altitude of 7000 feet MSL, all evidence points to the fact that it was never above 3000 feet MSL (700 feet above the terrain). Surviving crew members stated that after reaching an altitude of approximately 700 feet above the terrain, Captain Christian feathered the propellers of both left engines and continued to instruct First Officer * Upham m emergency procedures. Shortly after this, the crew began to realize that the airplane was getting dangerously low over a wooded area and rising terrain and that the situation was rapidly developing into an actual emergency. The captain took over the controls and attempted to restart the left engines. However, before sufficient power could be re stored the airplane began striking the tree tops. It crashed and burned several hundred feet beyond the point of initial contact with the trees. Investigation disclosed no evidence of mechanical failure or mal functioning of the aircraft or engines and, according to surviving crew members, the only irregularity during the flight was the intentional cutting of the left engines. Accoraa.ng to Northwest Airlines, this flight, while net subject to scneduled air carrier rules, was to be operated in a manner similar to their scheduled flights operating over the same route. A company representative stated that Northwest has at no time authorized the practicing of emergency procedures while the airplane is at a low altitude over a congested ?rea, or the feathering of propellers immediately after takeoff. Simulated emergency procedures arc permissible only during pilot checks and training flights. The airplane, carrier, and crew were properly certificated for the flight involved. Captain Christian held an airline pilot certificate and had flown approximately 3114 hours, of wnicn aoout 1669 had been on DC-4 equipment, First Officer Upham held a pilot certificate with commercial aril instrument ratings. hud flown approximately 2^06 hours, of wmeh 406 were m DC-4 equipment. Tie Board determines that the probable cause cf the accident was trie capwin's action in undertaking simulated emergency procedures at a danger- ously lorf altitude. BY THE CIVIL AnROMUTICS BOARD. /s/ JOSEPH J. 0*CONNELL. JR. /s/ OS' ALP RYAH______ /s/ JOSH LEE ____ /s/ HAROLD A. JONES Russell B. Adams, Heritor of the Board, end not participate m the adoption of this report. CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: January 18, 1951 Released: January 18, 1951 NORTHWEST AIRLINES, INC.---BENTON HARBOR, MICH., JUNE. 23, 1950 * The Accident in maintaining its assigned altitude. ARTC ,1^ estimated that the two flights would pass At approximately 2325, June 23, 1950, a C-54A-DC, N-95425, owned and operated by each other in the vicinity of Battle Creek, Northwest Airlines, crashed into Lake Michi- Mich., and that the standard separation of gan approximately 18 miles north-northwest of 1,000 feet would not be sufficient because of Benton Harbor, Mich, None of the 55 passen- the turbulence. At 2251, Flight 2501 re- gers and three crew members survived. The ported that it was over Battle Creek at 3,500 aircraft was destroyed. feet, and that it would be over Milwaukee at 2337. When in the vicinity of Benton Harbor, History of the Fl Ight at 2313, the flight requested a cruising al- The flight 2501/ was scheduled to operate titude of 2,500 feet; however, no reason was between the terminal points of New York, given for the request, ARTC was unable to N. Y. . and Seattle, Wash., via intermediate approve this altitude because of other and Seattle, Wash., and Spokane, traffic. Acknowledgment that ARTC could points of Minneapolis, Minn Wash. At epproximately 1931 the flight de- not approve descent to 2,500 feet was re- parted from LaGuardia Airport for Minneapolis ceived at 2315, aid this was the last com- with a crew consisting of Robert C. Lind, munication received from the flight. captain; Verne F. Wolfe, first officer; and At 2337, Northwest Radio at Milwaukee ad- Bonnie A. Feldman, stewardess. Qi board were vised the company at LaGuardia and Minneapo- 55 passengers, 2,500 gallons of fuel, 80 gal- lis, aid ARTC at Chicago, that the flight lons of oil, md 490 pounds of express, which was ten minutes overdue since they had in- resulted in an aircraft weight of 71,342 correctly copied the 2251 flight report as pounds for takeoff. This was 58 pounds below 2327. At 2345 Northwest Radio at Milwaukee the maximum permissible takeoff weight, and transmitted to the flight instructions to the load was distributed so that the center circle the range station at Madison, Yds. , if of gravity was within approved limits. The its r no transmitter was inoperative. flight plan filed with ARTC (Air Route Hiring the sane period, all CAA (Civil Aero- Traffic Control) specified a cruising altitude nautics Administration) radio stations in the of 6,000 feet to Minnefpolis. An altitude of Chicago-Minneapolis area tried to contact the 4,000 feet had been orginally requested be- flight on all frequencies. At 2358, Chicago cause-of forecast rn route thunderstorms, but ARTC, at the request of Northwest Airlines, denied by ARTC because other traffic was alerted air-sea rescue facilities in the assigned at that level. area, which included the Air Force, Navy, At 2149, when over Cleveland, Ohio, a Coast Guard, and the state police of Illi- cruising altitude of 4,000 feet was again re- nois, Michigan, Wisconsin, and Indiana. The (fuested by the flight and this time approved missing aircraft was assumed to have been in- by ARTC. Forty minutes later the flight was volved in an accident at. 0530 since the fuel requested by ARTC to descend to 3, 500 feet supply at that time would have been ex- because there was an eastbound flight at hausted. 5,000 feet over Lake Michigan which was ex- periencing severe turbulence and difficulty Investigation An intensive search of the Lake Michigan $ area was commenced at daylight June 24. On Ail times referred to herein are Central Stand- ard and baaed on the 24-hour clock. the following day, at 1830, the United States Comm--- DC--- 16881 (1) (oast (rtiard cutter '-oodbine found an oil Captain Lind and First Officer Vol fe slick, aircraft debris, aid the aircraft log arrived at the Northwest Flight Control Look in Lake Michigan approximately 18 miles Office at LtGuardia Field at approximately north-northwest of Benton Harbor. 1800, one hour before the scheduled departure At 0530 j June 25, underwater search opera- of Flight 2501. At that time the crew and tions were conducted with divers and sonar * the dispatcher discussed the weather situa- equipment. Divers descended at the points tion, and exanined the hourly sequence re- where strong sonar contacts were made. At ports relating to enz route and terminal those locations, the lake bottom was 150 feet weather. Company forecasts, Weather Bureau below the surface of the water and was forecasts, and Weather Bureau maps were covered by a layer of silt and mud estimated available and were examined by the crew. to be 30 to 40 feet deep. Visibility was Company and Weather Bureau forecasts indi- less than eight inches. The possibility of cated thunderstorms in the Detroit- locating anything was slight, and movement Minneapolis area with moderate to severe tur- was severely restricted. In addition to bulence above 10,000 feet, and light to mod- diving operations, the entire area was erate turbulence below 10,000 feet. For this dragged uith grapnel bu t wi thou t resu11s. reason Captain Lind and the dispatcher de- After two days of operation, the Navy sus- cided on a cruising altitude of 4,000 feet, pended their search because of the difficult but as previously mentioned, ABTC was unable conditions, and because nothing had been to approve that altitude and assigned a found which would indicate that the aircraft cruising altitude of 6,000 feet. In addition could be recovered. Since then, the Coast to the above, and of particular interest to Guard aid aircraft flying in that area have the flight, was a special thunderstorm fore- maintained a sea and air suveil lance. cast issued by the company at 1545 which The only parts of the aircraft that were read as follows: recovered were those with sufficient buoyancy to float: a fuel tank float, foan rubber Scattered thunderstorms along and east cushions, arm rests, clothing, blankets, of the cold front, bases at 3,OCX) to 4,000 pillows, pieces of luggage, cabin lining, feet, tops 30,000 to 40,000 feet with moder- plywood flooring end other wooden parts. The ate to severe tubulence at all levels in the cushions and arm rests, shredded from impact thunderstorm and moderate turbulence below forces and cutting edges of the fuselage, in- thunderstorms, advising flights below 10,000 I dicated that the aircraft struck the water at feet to proceed with caution in the frontal A zone, anticipating the activity to be at its high speed. A plywood oxygen bottle support bracket, which had been installed in the for- peak betw-een the hours of 2230 of the 23rd ward left side of the fuselage, showed that and 0400 of the 24th EST with possible the inertia forces acted in a forward, down- squall line development ahead of the front ward, and to the left direction. There was during the evening. no sign of fire found on any parts recovered. At 1845 a new forecast was issued by the An examination of all maintenance records company, but was received by the New York of N-95425 disclosed no irregularities. The dispatcher after the crew had left Flight last crew to fly the aircraft had reported it mechanic al ly okay for turn-around. The Control. Since this forecast called for aircraft had been given a preflight check better weather than the earlier one, the creto prior to takeoff and was airworthy in all re- was not advised. At 2133 the Weather Bureau spects.. issued a regional forecast for the period None of the radio cormiunicat ions received 2200 of June 23rd to 1000 of June 24lh, which from the flight, including the last, con- predicted widespread thunderstorm activity tained any mention of trouble. Although and a squall line extending from southern shortly before the accident the flight re- Wisconsin eastward into lower Michigan and quested an altitude of 2,500 feet, there was moving southward. The southern edge of the no indication that thn flight was experi- squall line was located west of Benton Harl>or encing difficulty at the 3, 500-foot altitude. at the approximate time of this accident. No reason for the request for the lower alti- The forecast containing information on the tude was given nor was an emergency declared. squall line was placed on the teletype one ---- 1J hour and 40 minutes before the accident, and that, it crashed shortly afterward. This fat the Flight Advisory Weather Service made it in itself indicates that the accident proba-" available to ARTC. However, regional fore- bly resulted from either a structural failure casts are not routinely broadcast. Tn this caused by the turbulence, or because control case the Flight Advisory Weather Service man of the airplane was lost. However, there is on duty dijl not request ARTC to warn flights no evidence upon which a determination can be of the squfcll line, nor did ARTC do so on made as to which of these two possibilities their own initiative. The company meteorolo- actually caused the accident. Accordingly, gist questioned the existence of a squall it must be concluded that there is not suffi- line at that time, and consequently no advice cient evidence from which the probable cause concerning it was furnished the flight by the of.this accident can be determined. comp any. f Findings Several flights flew over the southern Lake Michigan area for a period of one hour On the basis of all available evidence the after and one hour before the accident oc- Board finds that: curred. The pilots stated that they en- 1. The carrier, crew and aircraft were countered moderate to severe turbulence, fre- properly certificated. quent cloud-to-cloud and cloud-to-ground 2. Prior to takeoff, the crew was thor- lightning, but no hail. Several flights oughly briefed regarding the en route and successfully circumnavigated the storm by terminal weather, which included a forecast flying to the south. Three that took off of thunderstorm activity and the possible de- from Detroit after midnight of June 24th re velopment of a squall line. turned because of turbulence encountered at 3. A forecast was issued one hour and 40 I accident, and while the the edge of the storm. One pilot who re- minutes prior to the turned to Detroit stated that he was unable flight was en route, in which was described to fly over the storm because it extended the development and location of a squall over 30,000 feet. line. This forecast was not made available Analysis of both the official meteorologi- to the flight. cal data and testimony of witnesses indicates 4. No report of difficulty in the opera- that the squall line was quite severe and tion of the aircraft or any of its components that its southern edge was located at or near was received from the flight. the location of the accident at time of acci- 5. At 2313 the flight requested a lower dent. altitude but because of conflicting traffic, the request was denied. Analysis 6. At the approximate time of the accident Impact damage found in fragments of the a squall line was located in the area where aircraft that were recovered showed that the the aircraft crashed. airplane struck the water with considerable 7. Despite an intensive surface and under- force. It was not possible to determine from water search, the aircraft was not located these few fragments whether there had been with the exception of a few fragments. any failure prior to the time of impact. From the evidence available, there are no Probable Cause definite conclusions to be drawn. A possi- The Board determines that there is not bility that this accident resulted from some sufficient evidence upon which to make a de mechanical failure seems to be remote, for no termination of probable cause. indication of trouble was contained in any of the communications received from the flight. BY THE CIVIL AERONAUTICS BOARD: Furthermore; the aircraft maintenance rec- ords, the flight report from the last crew who had flown the aircraft, and the inspec- I si D. V. RENTZEL tion which was accomplished just prior to Is! JOSH LEE takeoff, all are to the effect that this air- I s! HAROLD A. JONES pl fme was in an airworthy condition. It is known that the flight entered an Oswald Ryan, Vice Chairman, did not par- area where there was severe turlwlence and ticipate in the adoption of this report. 15881 Supplemental Data t Investigation and Hearing had satisfactorily completed a six-month in- Notification of this accident was received strument flight check on February 10, 1950. by the Civil Aeronautics Hoard from the CAA He also satisfactorily completed an annual Cojnnunications Station at Chicago. An in- line flight check on March 28, 1950. vestigation was immediately initiated in ac- Verne F. Wolfe, copilot, age 35, was em- cordance with the provisions of Section 702 ployed by Northwest Airlines May 21, 1943. (a)(2) of the Civil Aeronautics Act of 1938, He was checked out in DC-4 type aircraft as as amended. As part of the investigation a of August 8, 1946, and maintained his quali- public hearing was held July 13 and 14, 1950, fication continuously since that date. at Chicago, 111. During the 90 days prior to the accident, he had flown 82 hours in DC-4 type aircraft and Air Carrier had flown 13 round trips over the Minneapolis-New York and Minneapolis- Northwest Airlines, Inc., is a Minnesota corporation having its principal place of Washington routes. business at 1885 University Avenue, St. Paul, Copilot Wolfe held a valid airline cer- Minn, lhe company is engaged in the trans- tificate No. 15276 3 with conmercial single, portation by air of persons, property and multi-engine land and instrument ratings. He mail, and holds a certificate of public con- had Jogged a total flying time of 3,821 venience and necessity issued by the Civil > ours, of which 470 hours were accumulated in Aeronautics Board which authorizes it, among DC-4 type aircraft. His total instrument other things, to operate between New York, flying time was 400 hours. Prior to de- N. Y., and Seattle, Wash., via various other parture from LaGuardia, he had a rest period intermediate points. The carrier also holds of 24 hours. Copilot Wolfe completed a first an air carrier operating certificate issued class CAA physical January 19, 1950. by the Administrator of Civil Aeronautics. Aircraft Flight Personnel N-95425, a C-54A-DC; currently certificated Robert C. Lind, the captain, age 35, was by the Administrator of Civil Aeronautics, employed by Northwest Airlines May 8, 1941. was owned and operated by Northwest Airlines. r It was manufactured September 5, 1943, and He was checked out on a DC-4 type aircraft June 23, 1946, and qualified over the originally operated by the United States Air Milwaukee-New York segment on April 28, 1945. Forces and later by Linea Aeropostal He maintained his qualification in DC-4s and Venezolana. It was purchased by Northwest had flown over the route continuously since Airlines April 11, 1947, and entered sched- the above dates. Fairing the 90 days prior to uled Northwest Airlines service on June 25, the accident, he had flown 105 hours in DC-4 1947. On April 25, 1950, it was converted to type aircraft and had flown 15 round trips a 55-passeoger cargo-coach aircraft. At the over the Minneapolis-New York and Minneapo- time of the accident it had a total of 15,902 lis-Washington routes. flight hours and 1,692 flight hours since the He was the holder of a current airline last major overhaul. The engines, four Pratt transport pilot certificate No. 63357 with ft Whitney, Model 2SD13-G, 1450 horsepower, single and multi-engine land ratings, 0 to had been flown one through four, respectively: 7200 horsepower. He had logged a total of 8,840 hours; 29 hours; 8,935 hours; 11,129 8,662 flight hours, of which 1,968 were ac- hours; and all engines had accumulated 623 cumulated in DC-4 type aircraft. Captain hours since the last overhaul, lhe aircraft Linds total instrument time was 914 hours. was equipped with four Hamilton Standard During the month of June 1950 he had accumu- propellers,. Model 23E50, and the total time lated 58 hours. Prior to departure of Flight on the propellers, one through four, respec- 2501 from LaGuardia, be had a total rest tively, was: 4,677; 4,677; 9,854; 9,854; and period of 24 hours. He had. completed a first each propellei had accumulated 623 hours class CAA physical February 13, 1950, and since overhaul. (I) CIVIL AERONAUTICS SOARD Adopted: August 27, 1951 Released: August 30, 1951 NORTHWEST AIRLINES, INC., MINNEAPOLIS-ST- PAUL INTERNATIONAL AIRPORT, MINNEAPOLIS, MINNESOTA, MARCH 18, IS5I THE ACCIDENT at 1053 At 1022 it receiveo clearance from At approximately 1107, 1 March 18, 1951, a Air Route Traffic Control to cross Hamel at Douglas PC-4 aircraft, N~ 95426, owns a by I? 3,500 feet, to maintain 3,500 feet, that no r< Northwest Airlines, Inc., ana operating as delay was expected, and to contact tanne- Flight ]08, landed m deep snow adjacent to apolis approach control when over Hamel At Runway 29-L at the Minneapolis-St Paul 1036 the flight advised beginning descent International Airport, Minneapolis, Minne- from 5,009 feet and vas given the 1030 Mume- sota There were no injuries to the 13 pas- apolis weather Precipitation ceiling sengers and 1 infant or to the 4 crew members 1,600 feet, sky obscured, visibility one mile, aboard The aircraft was substantially variable with light snow, and blowing snow, damaged with the remark that the visibility was "variable between three-quarters and one and HI STORY OF THE FLIGHT one-quarter miles This message was ac- Flight 108 departed Portland, Oregon, on knowledged by the flight At 1051 Flight March 17, 1951, for Minneapolis, Minnesota, 108 reported over Hamel and advised that it with scheduled stops planned which included was changing to Minneapolis Approach Control Billings, Montana, and Fargo, North Dakota frequency Tins facility was contacted, and A routine crew change was made at Billings acknowledged the position report The 1030 The new crew consisted of Captain T Franklin, Minneapolis weather was transmitted, fol- First Officer A Keller, and Stewardesses lowed by a clearance to the outer marker to M Keenan and M Drury. maintain 3,500 feet The flight acknow- Flight 108 was off the ground at Fargo at ledged this clearance after which the cap- 0950, March 18, on an instrument flight plan, tain was advised by Approach Control to to cruise at 5,000 feet to Minneapolis. The change to company frequency, to give them a terminal weather forecast for Minneapolis call, and then change back to approach con- available to the crew at the time of depar- trol frequency Thereupon the company was ture indicated a precipitation ceiling of called and at J055 the flight received the 1,000 feet and visibility of three-quarters message that, "Reports indicate the approach of a mile, ceiling variable from 500 to 1,500 lights on Runway 29-left are hard to see feet and visibility variable from one-half Might be covered with snow " This was ac- to one and one-half miles The total weight knowledged by the flight At J058 Flight of the aircraft at departure from Fargo was 108 was instructed by Approach Control to 54,025 pounds, which was within the allow- descend to 2,500 feet and to advise when able gross limit of 65,000 pounds, and all leaving 3,500 feet Descent was begun disposable load was so distributed that the immediately and upon arriving at 2,500 feet aircrafts center of gravity was within Approach Control cleared the flight for an certificated limits. ILS (Instrument Landing System) approach and At 1021 the flight reported over Alexan- advised it to report when over the outer dria, Minnesota, and estimated over Hamel2 marker inbound, also that Runway 29-left was Uli times referred to herein are Central the run wav in use and that the wind was Standard and based on the 24-hour clock northwest variable to north at 15 miles per ^Hamel is a standard airways fan marker on the hour The following remarks were aaded by northwest course of the MSP radio range 24 miles Approach Control to the clearance ^Northwest from the range station Comm.---*-DC---38309 (1) 108, Minneapolis Approach Control, a report to rest in a nose-down tail-high attitude on on the runway, Runway 29-left, there is an approximate heading of 293 degrees mag- about eight to ten inches of fresh snow on netic These measurements place it at a the first third of the runway from the south- point 874 feet northwest of the threshold east end as far as the north-south runway, and 96 feet to the right of the runway then from the north-south runway northwest, There was no visible damage to the main the runway is m good condition The runway landing gear Nos 2 and 3 (the inboard) has been plowed from the nor th-south runway, propellers were damaged and the radio loop northwest antenna was broken off The nose cap assem- At 1104 Flight 108 was asked if it had bly was damaged beyond repair The nose completed the procedure turn inbound The wheel well doors, several bottom structural reply was that the flight was over the outer frames and stringers, as well as some areas marker inbound and it was instructed as fol- of the aircrafts skin, were damaged, re- lows 108 at the outer marker inbound, quiring replacement cleared to land and the wind is indicating Inspection of the pilots control compart- north-northwest at 15 to 20, expect cross- ment indicated that all the aircrafts con- wind from the right and there is 8-10 inches trols, including engine, fuel, electrical of snow on the first third of the runway. and radio, were m their respective correct The flight reported having the field in positions, the flap control lever was down sight at 1105, and at 1106 the control tower and the flap-position indicator showed that sighted the aircraft approximately over the the flaps were down 45 degrees end of the runway in a shallow right bank. Runway 29-left at the Minneapolis-St Paul It was then levelled off and placed m a International Airport is concrete, 6,500 shallow left bank, again levelled off and feet long, 200 feet wide, and is approved by almost inmediately made contact with the sur- the CAA for ILS straight-in approaches The face of the deep snow to the right of Run- southeast half of this runway on the day the way 29-left It continued ahead for a short accident occurred was covered with eight to distance until the nose gear collapsed caus- ten inches of fresh snow This fact made ing other damage. recognition of the approach end of the run- The accident occurred at 1107, and the way extremely difficult The northwest or local weather observation at 1100 indicated far end of this runway had been plowed and ceiling, precipitation 1,500 feet, sky ob- the runway lights in this area were clearly scured, visibility one mile variable, light visible to aircraft on the ground in that snow, blowing snow, wind nor th-northwest at vicinity However, under the poor visibil- 15 mph, altimeter 2971, visibility variable ity conditions, this snow clearance would be 3/4 to 1 1/4 miles no help to aircraft attempting to land on the opposite, or unplowed end. The Bartow INVESTIGATION runway lights marking the right and left Investigation revealed that the aircraft sides of the runway are placed 200 feet touched down approximately 600 feet north- apart longitudinally, and are 27 feet from west of the southeast end of Runway 29-left each edge of the runway These lights are and approximately 96 feet to the right of approved by the CAA and testimony indicated the runway. Snow at this point was from that they were illuminated at their highest four to five feet deep, m drifts. Wheel intensity, 180,000 candle power, at the time marks indicated that the nose wheel touched of the accident However, Captain Franklin down approximately 18 feet before the main stated that he saw no lights burning at any wheels. The aircraft plowed through the time during the approach and landing snow m a nearly straight line for a distance Ekie to the heavy snow condition at the of about 274 feet Approximately 93 feet time of the accident, these runway lights from the initial touchdown of the nose wheel, were marked by small red streamers, 18 inches the nose gear collapsed and folded rearward by 2 inches, mounted on two-foot staffs at- It was severed from the aircraft structure, tached to each runway light The taxi strip and was found m the snow about 86 feet be- adjacent to and paralleling Runway 29-left yond the point where it collapsed Ninety- also has Bartow lights on both right and left five feet from this point the aircraft came sides as well as on its end Due to neavier snow along this taxi way, larger obstruction half before This flight advised the com- marker flags, 18 inches by 24 inches, were pany that the runway lights were hard to see, used to mark these lights The purpose of adding that they might be covered with snow these flags is to indicate the locations of This pilot report was relayed to Flight 108 these lights to avoid damage by snow removal during its approach Showfall had been con- equipment tinuous since about midnight of March 17, Funway 29-left is also provided with an together with blowing snow, which caused approach lighting system which is a component variable visibility conditions and this con- of the ILS installation. These approach tinued throughout the day. lights begin at a point 200 feet southeast Captain Franklin had been flying from the from the threshold of the runway and extend Minneapolis-St Paul International Airport for a distance of 3,050 feet toward the for several years and was thoroughly familiar southeast This approach lighting installa- with the field and the usual winter diffi- tion consists of 29 bars or rows of lights culties caused by snow conditions IXiring placed about 100 feet apart longitudinally. this approach he stated that the ground was Each of these bars is 14 feet wide upon visible from 3,000 feet and that at 2,100 which five lights are mounted These lights feet, shortly before arrival over the middle are clear in color and are of a maximum can- marker, he became contact and had the field dle power of 90,000 each. This row of ap- m sight. Also, he stated that he had no proach lights is located 117 feet to the left trouble recognizing the airport area or the of the center line of Bunway 29-left ex- surrounding terrain with which he was famil- tended The lights are beamed toward the iar. Shortly after becoming contact and at approaching aircraft coiranensurate with the a low altitude, the approach-light structure angle of the glide path and are approximate- was seen to be slightly to the aircraft's ly at the elevation of the runway Tower right. Shallow right and left turns were personnel testified that they were operating made to align with the runway, at which at their highest intensity. time several flag markers were seen and al- A Notice to Airmen (NOTAM) announcing the most immediately additional markers were ob- date of the commissioning of the ILS serving served to the right of these The observed Rinway 29-left as March 6, 1951, was pub- flag markers outlined the north edge of the lished by the Civil Aeronautics Administra- runway and the south edge of the taxi-strip, tion on March 5, 1951 This notice contained respectively an error in stating that the center line of Captain Franklin had never made an instru- the approach light lane was 177 feet south of ment approach to Bunway 29-left however, he the runway center line extended. This NOTAM had made several visual approaches to this was posted on the pilots' bulletin board in runway which had been coiunissioned for ILS NWA operations office and was read by Cap- approaches only twelve days prior to the ac- tain Franklin prior to departure of Flight cident- The airport was described as a sea 108. He added that he was aware that this of snow, unbroken and without contrasting must have been a discrepancy and that he was features or lines ot delineation which would in no way confused by it, that the error m have indicated the relative position of the the publication did not influence him. runway on the airport as a whole. A second NOTAM da^ed March 6, 1951, was The captain stated that the ILS localizer published announcing the actual coranission- and glide-slope transmitters were operating mg of the facility and stated properly that normally as well as the receivers and other the light lane was 117 feet south of the run- electronic equipment in the aircraft way center line extended This notice was not posted on the pilots bulletin board. ANALYSIS On March 22, 1951, a NOTAM was published Flight 108 became contact at 2,100 feet correcting the typographical error made on MSL (Mean Sea Level) shortly before arrival the March 5, 1951, issue and this was posted over the middle marker. The pilot stated he on the NWA pilots bulletin board had the airport and the approach light struc- The last aircraft to land on Bunway 29- ture in sight at this point but could not left previous to the accident was NWA Flight distinguish the runway from the whole air- 500 which landed approximately an hour and a port area due to the snow condition ---38309 He elected to abandon the ILS approach and extremely low altitude, the captain showed to continue the descent visually as the air- poor judgment in not executing a missed ap- craft was properly aligned with the runway proach procedure at this time. Due to the varying visibility caused by FINDINGS blowing snow, it may be reasonably assumed that the pilot momentarily lost sight of Oh the basis of all available evidence, the board finds that landmarks, such as the approach light struc- 1 The company, the aircraft, and the crew ture which he was using for guidance, and were properly certificated thereby lost the alignment he haa previously 2 There was no malfunctioning of the established. This could explain aircrafts later position to the left (or wrong side) aircraft or any of its components prior to of the approach-light structure Also, the the accicent coincidence of seeing the widely spaced flag 3. The flight started an ILS straight-m approach to Runway 29-left and in the vi- markers, after the corrective turns were cinity of the middle marker abandoned the in- made, may have been sufficient to assure the strument approach and continued V1R to the pilot that his directional corrections had placed him in line with tie runway Under 1and mg 4. The runway and runway lights were par- the reduced visibility conditions this false indication of the location of the runway can tially obscured by snow be understood Fianklin had PROBABLE CAUSE On the other hand, Captain been warned that the approach end of the The Board determines that the probable runway had not been plowed and that the run- cause of this accident was the failure of the pilot to identify properly and align the way and runway lights were difficult to see aircraft with the assigned runway due to Since this information had come from a snow coverage and poor visibility. pilot of one of the companys aircraft which had landed an hour and a half previous, and since snow had continued to fall during the BY THE CIVIL AERONAUTICS BOARD intervening time, it should have been obvious /s/ DONALD W. NYROP that these conditions had worsened In addi- Is/ JOSH LEE tion, Captain Franklin said that the visibil- /s/ CHAN GURNEY ity decreased as the aircraft neared the boundary of the airport. In view of the foregoing adverse condi- Oswald Ryan, Vice Chairman, and Joseph tions and the fact that the aircraft was not P. Adams, Member of the ard, did not par- properly aligned with the runway at its ticipate in the adoption of this report. --- 38309 Supplemental Data INVESTIGATION AND HEARING FLIGHT PERSONNEL The Civil Aeronautics board was notmed Captain Toy W. Franklin, age 41, held a of the accident involving Northwest Airlines, valid airline transport pilot rating. He Inc , at Minneapolis, Minnesota, bv CAA Com had a total of 15,086 flying hours. 1 is niiinications, Minneapolis, Minnesota, at last instrument check was accomplis I tea on 1300C, March 18, 1951. An investigator from September 1950, and bis last CAA phy- the Board's Chicago office proceeded to the sical examination was December 15, 1950 scene of the accident and an investigation First Officer Archie C Keller, age 32, held was inmediatelv initiated m accordance with a valid airman certificate with a commercial the provisions of Section 702 (a) (2) of the pilot and multi-engine instrument rating. Civil Aeronautics Act of 138, as amended. He had a total of 3,597 flying hours His A public hearing was ordered by the board and last CAA physical examination was accom- was held in Minneapolis on April 4, 1951. plished August 16, 1950. The other crew members were the stewardesses, Marilyn Ann AIR CARRIER Drury and Margaret Keenan. Northwest Airlines, Inc., is incorporated in the State of Minnesota and maintains its THE AIRCRAFT principal place of business at Minneapolis, N-95426, a Douglas DC-4, manufactured on Minnesota. Northwest Airlines, Inc., pos- November 15, 1943, bad a total of 20,115 fly- sesses a certificate of public convenience ing hours and was currently certificated by and necessity and an air carrier operating the Civil Aeronautics Administration. It was certificate which authorizes the carriage of equipped with four Pratt 5 Whitney engines, persons, property and mail, over the route 2SD13G and the propellers were Hamilton described in this report. Standard Hydromatic, full feathering type ---38309 k SA-255 File Ho. 1-0017 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: November 9, 1955 Released: November 14, 1955 NORTHWEST AIRLINES, INC., - SANDSPIT, BRITISH COLUMBIA, JANUARY 19, 1952 Introduction This report is a revision of tbs Boards original accident investigation f report released September 15, 1952. In accordance with the Boards policy of keeping accident investigations open for consideration of new evidence, continuing study was carried out by the Bureau of Safety Investigation subsequent to release of the original report. This study resulted in the disclosure of nose gear malfunctions by review of service difficulties on DC-4 aircraft for a considerable period subsequent to the accident, the development of additional facts by detailed examination of the nose gear wreckage of N 45342, and the submittal of supplemental information relative to the handling characteristics of the DC-4 during takeoff with three engines operating. The weight of the new evidence w; rranted adoption of a revised report with a new Probable Cause. The Accident Northwest Airlines Flight 324, a Douglas DC-4 N 45342, crashed in Hecate Strait less than a mile offshore (See Attachment II), following an attempted precautionary landing at the Sandspit, British Columbia, airstrip, January 19, 1952, about 0138.1/ Seven of the 40 passengers but none of the three crew mem bers survived. The aircraft was substantially damaged upon impact, and subse- quently was destroyed by action of tides. History of the Flight The flight originated at Tokyo, Japan, for McChord. Air Force Base, Tacoma, Washington, via Shenya and Anchorage, Alaska. During the scheduled stop at Shesya, a crew change point, one magneto was changed on No. 1 engine. The balance of the trip to Anchorage was completed without incident, and the incom- ing crew reported no malfunctions. Another crew change was made at Anchorage, with the new crew consisting of Captain John J. Pfaffinger, First Officer Kenneth H. Kuhn, and Stewardess Jane Cheadle* The pilots were briefed on weather and route information prior to departure from Anchorage. Forecasts indicated that weather conditions at the planned ~~ t/ All times r . i sri -<1 to tv i e in are Pacific Standard and based on the 24-hour clo l. T cruising altitude of 10,000 feat would be instrument, sky condition generally broken to overcast, with two or more cloud layers. The freezing level rose along the route, being on the surface at Anchorage, 5C0 feet at Sandspit, and 2,000 feet at Seattle. Occasional light aircraft icing and light turbulence were forecast. Precipitation in the form of snow showers at both surface and flight level was predicted between Anchorage 3U2 for use in the military air lift. Its maintenance records disclosed that certain component parts of the engine in stalled in the No. 1 position, (this was the feathered propeller) had at the time of the accident exceeded the permissible tune of 1,500 hours betwee over- hauls. This engine had previously been given a top overhaul by Air Works, Inc. for TWA and shipped to Northwest Airlines Seattle base on October 21, 1951, where it was installed In another DC-h. Northwest Airlines at Seattle was ad- vised by TWA that the time since overhaul on this engine was 790 hours and 5>0 minutes. Through oversight, this message was not forwarded to Northwest Air- lines' St. Paul Routing Office. (Normally TWA transmitted such information direct to St. Paul). After 555 hours and 16 minutes of additional operation, thia engine was installed in N i*53U2, where it had accumulated 379 hours and 10 minutes at the time of the accident, or 225 hours and 16 minutes in excess of the 1,500 hours allowed between overhauls. The oil cooler reported by the flight as broken was one of the accessories that had been in service only 93U hours and 26 minutes. Rumray length and condition at Sandspit were satisfactory to accommodate the DC-Uj and the captains decision to land there was therefore In conformance with good operating procedures# Under the circumstances of load, speed, and braking conditions at the time, the distance remaining on the runway from point of touchdown sight be considered marginal ? and a successful stop may or may not have been possible; the attempted go-around, therefore, may have been necessary Although the captains handling of the situation following feathering of the No# 1 propeller was in conformance with Civil Air Regulations and company operating procedures, it would appear that with one engine out on a sub-Arctlc overwater flight, at night, and under IFft conditions, it would have been highly desirable for the captain to have prepared the aircraft and passengers for a possible ditching. This probably would have resulted in less loss of life. Subsequent to this accident, Northwest Airlines began a study of improve- ments in procedures and the desirability of relocating or installing addittanal emergency equipment on aircraft operated on overwater flights. The ditching pasphlet has been supplemented by oral brief Inga of passengers on location of emergency exits and how to open them; location of life rafts, how to remove them, and instructions on Inflation; and personal demonstration to groups of four passengers in the use of life vests. Similar changes relative to survival equipment and procedures have been made in the Civil Air Regulations. After No. 1 propeller was feathered, it was demonstrated that the aircraft had sufficient power from three engines to climb without difficulty in the clean configuration. Thus the power being developed at that tine probably was adequate for the climb after takeoff at Sandspit, although the two situations are not directly comparable# Of course the possibility remains that ihe same amount of power developed in the previous three-engine climb,was not developed at Sandspit, due to possible carburetor icing or other factors which would reduce horsepower output# Since it was impossible to conduct a teardown and ex ami nation of the engines, no concrete statement can be made regarding their condition. Possible ice accretion could have lowered airfoil efficiency in the climb following takeoff, since weather conditions 'at Sandspit were favorable to formation of light icing on the aircraft structure. Pilots would norsally retract flaps to 15 degrees for a go-around divers estimate that the flaps appeared to be down about hO degrees night be correct; however, the flap position may have shifted due to tide action or towing the aircraft backward# The flap handle was found in the neutral position which suggests that the pilot moved it from the full down position and retracted flaps during acceleration. None of the evidence on this Batter is conclusive, but if the flaps were at 15 degrees, climb performance would have been consid- erably better than at a l*0-l*5-degree position At the request of the Board, the Douglas Aircraft Company furnished a series of curves plotting air speed versus rate of climb for a DC-1* operating on three engines at rated takeoff power and with the propeller feathered on the inoperative engine. Without consideration of ground effect, these curves were computed for sea level at a gross weight of 62,1*79 pounds, the estimated weight of Flight 321* at the tine of the accident. They show that the best rate of climb with 1*5 degrees flaps and landing gear down would be 15 feet per minute at approximately 98 miles per hour; however, ground effect for approxi- mately the first fifty fest of altitude would increase the rate of climb appre- ciably, With 1*5 degrees flaps, gear up, the best rate of climb would be 200 feet per minute at about 108 miles per hour; 1*20 feet per minute could ba realised with 30 degrees flaps, gear up, at an air speed of about 118 miles per Thus from the time the aircraft first broke ground to the time that the landing gear was fully retracted the rate of climb would have been low. At air speeds both below and above those noted, the rate-of-dimb curves fall off rapidly. In considering the flight characteristics of the aircraft at the applicable weight, a climb would have been possible with flaps extended 1*0 to 1*5 degrees if proper airspeeds were maintained, three engines continuously devel- oped rated takeoff power, the airplane was free of Ice, and the landing gear retracted without malfunction. Lt. Baker testified that he believed buffeting was present and that the aircraft was very near the stalling point during the attempted go-around. Be also stated that deceleration at impact was rapid but not violent. This could iadicata that the air speed of the aircraft was low and wind effect was nagli- gible. Thus Lt. Baker's testimony indicates the possibility of Insufficient airspeed for climb If malfunctioning of the nose gear retraction system occurred during the attempted go-around it is likely to have caused failure of the rods actuating tie nose wheel well doors. The doors then could have caused the buffeting wtich Lt. Baker noticed. A partially retracted nose gear would also cause deterioration of the climb performance. The evidence that the nose gear was torn fro the airplane while in the up and locked position does not preclude the possibility of malfunction. Service experience indicates that extension of the landing gear after nose gear malfunction, followed by a second retractio usually results in completion of the retraction cycle, * twen the takeoff and the crash was probably sufficient for the above sequence of events. The directional controllability of the DC-4 during three-engine takeoffs is such that the effect of a fully deflected rudder is insufficient to counter- met the turning moment due to the unsyaaetrieal thrust at any speed appreciably below the safe takeoff speed. As a result, pniUgg the nose wheel off the ground in an attempt to take off at these lower speeds results in the aircraft Jfl Since, In this case, the aircraft did not strike the wnow banks lining the runway, it is apparent that the takeoff was not made at any speed appreciably lower than the recommended takeoff and climb speed. In regard to the overtime of No. 1 engines f was used beyond its maximum allowable overhaul period because of a clerical error of omission. A company official testified that since spare powerplants received from TWA were generally newly overhauled units, it was apparently assumed by the St. Paul Hout mg Office where such records are kept that a complete overhaul had been accomplished on this engine. It, therefore, appears that this overuse of the engine was without intent to exceed the overhaul limitations. The conditions that allowed this error to occur have been cor** rected by the carrier to the satisfaction of the CAA. Findin On the basis of all available evidence, the Board finds that: 1. The company, the aircraft, (with the exception of certain coinponente of No. 1 engine), and the crew were properly certificated. 2. The No. 1 engine suffered an oil loss, which necessitated shutting down the engine and feathering the propeller. 3. In accordance with company operating procedures, the captain elected, to land at the first available airport, rather than continue to destination on i The landing at Sandspit was aborted and a go-around was started 5. When last observed by a ground witness, the aircraft was in a shallow left bank at low altitude. 6. During the attempted cliabout, the aircraft settled into the water, bounced, and came to rest 26 degrees to the left and approximately 4,500 feet from the end of the runway* : seme all or nearly all of the passengers evacuated the aircraft with no known serious injuries, drownings and exposure accounted for 36 fatalities due to near freezing air and water temperature. 8. No steps were taken to prepare passengers for a crash landing or possible ditching. 9. Emergency lighting in the cabin was not utilized, nor were any effective measures taken to use life rafts stowed at the rear of the cabin Probable Cause The Board determines that the probable cause of this accident was a nose gear retraction difficulty in connection with an icing condition or a power Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareZwiation.com r j o \ / loss, which made the aircraft incapable BI THE CIVIL AERONAUTICS BOARD: /a/ JOSEPH P, ADAMS /s/ JOSH LEE // HARMAR D. DENN! Chan Gurney, Member, did not participate in the adoption of this report SUPPLEMENTAL DATA The Civil Aeronautics Board was notified of this accident ty CAA Com- cations at approximately 0200 on January 19, 1952. An investigation was iwaediately initiated by the Department of Transport of the Canadian Govern- ment and in accordance with procedures of the International Civil Aviation Organisation, a representative of the Board participated as an official observer The Boards investigation proceeded concurrently with the Canadian inves- tigation and was immediately initiated upon notification of the accident in accordance with the provisions of section 702 (a) (2) of the Civil Aeronautics Act of 1938, as amended. A public hearing was ordered by the Board and was held in the Washington Athletic Club, Room I4OO, 6th and Union Streets, Seattle, Washington, on April 2-4, 1952. An invitation was extended to the Canadian GsYemnent for one of its representatives to attend the Boards hearing, and an official of the Department of Transport was present as an observer for his government. Hie hearing was reopened at St. Paul, Minnesota, on August 10, 1955. Air Carrier Borthwest Airlines, Inc., is a Minnesota corporation, with its principal offices at 1885 University Avenue, St. Paul, Minnesota. The company is engaged lathe transportation by air of persons, property, and mail under certificates of public convenience and necessity issued by the Civil Aeronautics Board, and an air carrier operating certificate issued by the Civil Aeronautics Administra- tion for operations over the route described in this report. Northwest Air- lines operates airlift flights across the North Pacific pursuant to a contract with the U. S. Air Forcej the flight involved was such a military contract Captain John J. Pfaffinger, age 38, was employed by Northwest Airlines, Inc,, on August 4, 1942. He was the holder of a valid airman certificate with an air transport rating for multi-engine land aircraft Captain Pfaffinger had a total of 8,557 flying hours, of which 1,762 were in DC-h equipment, and 1,197 hours of instrument flying time. His last instrument check was accoja pl is bed on October 22, 1951, and his last en route check was given on Sovesber 17, 1951. Captain Pfaffinger received a CAA physical examination on September 24, 1951. First Officer Kenneth H. Kuhn, age 32, was employed by Northwest Airlines Inc., on September 13, 1945. He was the holder of a valid airman certificate nth commercial pilot and instrument ratings, c 1 hours, of which 1,698 were in DC-4 aircraft. His last CAA physical examination was accomplished on August 20, 1951 Stewardess Jane Cheadle had been employed by Northwest Airlines, Inc sssce April 1, 1950. The Aircraft N 453U2, a Douglas DC-I4 (C-5l|E), Serial No. 27279, owned ty Trans World Airlines, Inc., was operated on lease by Northwest Airlines. It had a total of 18,859 flying hours and was currently certificated by the Civil Aeronautics Administration. The aircraft was equipped with four Pratt & Whitney R-2OOO engines and Hamilton Standard 23E5O propellers. A No. 2 check on. the air- craft was completed at Seattle, Washington, on January 15, 1952. / / / V / A TTACHMENT I *4 0 4 NORTHWEST IRLINES, INC 4 a 5 /a wi ACCIDENT, SANDSPIT, B C \ JANUARY 19, 1952 6 I \ ! / ' f 7 I / I Pertinent radio contacts, shown in Pacific I Standard, are not ver*' tim I I Positions ore approximate, based on dead I reckoning position of the flight of time of trans- X I mission or receipt of messages by the flight I 'I1* i,,- Prepared by the Bureau of Safety Investigation, e* I- nt e r Civil Aeronautics Board I / 1/ Source Pert men! portion of Aeronautical Planning Chart 3069a, s! U S Coast and Geodetic Survey< / * i 9 1' % RADIO CONTACTS. FLIGHT 324 sl ^Mto ......I 'I 1 I l! I - Takeoff, Elmendorf Air Force Base, 2111, 1-18-52. I) 2- Over Anchorage range station 2123, climbing VFR, estimating Whittier 2138. (2127) 3- Over Whittier 2138, 10,000* estimating Middleton Island 2210 (2145) II I 4- Over Middleton Island 2209, lO.OOOj estimating > 90 degrees abeam Yakataga 2230, requested <2 change of altitude to 0,000', (2213) 5- ARTC cleared Flight 324 to descend to and 13 maintain BjDOO* Descent begun immediately (2215) \ 6* Cruising at 8,000* at 2222 (2224) 14 a IS pOO', estimating south- 16 7-Abeam Yakataga 2230, west leg of Yakutat range at 2259 (2234) * > 0- Southwest leg Yakutat range 2302, 8,000*, r? "X & SSugL estimating southwest leg of Gustavus range A c at 2231 (2305) -fc W fc> 9- Southwest leg Gustavus range 2330, , on a course of 097 degrees magnetic to the Omni Range, located on the airport, or 096 degrees to the low-frequency range, which is located 1.5 miles from the airport. If the field is not sighted or the landing accomplished by the time the aircraft reaches that point, the missed approach pro- cedure must be followed. A special flight check of communications facilities and navigational aids following the accident revealed that the Alberton Fan Marker and Missoula Omni Range were operating within prescribed limits. Communications with either Federal Aviation Agency or Northwest Airlines ground stations were satisfactory above 6,000 feet m.s.l. from Missoula to a point approximately 20 nautical miles north- west of the Alberton Fan Marker. Analysis and Conclusions The evidence supports the conclusion that the flight was properly dispatched, m accordance with company procedures. The flight crew was properly certificated and currently qualified m the aircraft and over the route from. Spokane to Missoula, and had had sufficient off-duty time prior to the flight, The aircraft was properly certificated and loaded within allowable limits. All radio conversations between the flight and ground stations gave no indica- tion that anything had gone wrong. The estimated arrival time over the Missoula Omni Range calculated by both the flight and Great Falls Center was identical, therefore, there was no apparent reason to suspect that the flight's progress would be anything but as planned. The approach clearance to the Missoula Airport issued by Great Falls Center to the flight at 1136 meant that no traffic existed that would conflict with the flights planned approach and that it was cleared to continue. In comparing the 0957 and 1057 reports of the Missoula weather, the overcast lowered 1,100 feet but the visibility increased 20 miles. Then, during the tune the flight was en route, the clouds forming the overcast at 3,900 feet began break- ing up and raised 400 feet. There was an overcast at 6,500 feet - 3,500 feet above the minimum approach altitude over the field. This latter conclusion is supported by the 1159 observation 20 minutes after the accident. Exactly what the conditions were at the Missoula reporting station at 1139 is not known, but the trend was toward improvement. The testimony and evidence bear out the fact that ceilings and visibilities usually are considerably lower m the mountains than over the reporting stations and were, m fact, lower in this case. Weather Bureau data revealed the existence of light to moderate icing con- ditions probably m clouds and precipitation above the freezing level, which was O,500 feet m.s.l. between Spokane and Missoula. Light to moderate turbulence should have been present from the surface to 9,000 feet on the route from Spokane to Missoula. The average cloud bases in the vicinity of the accident site were at or near 5,000 feet m.s.l., with haze and light showers. Tops of the mountains above 5,000 feet m.s.l. were obscured by the overcast. The visibility was from one to three miles with one mile in light showers. The Board is of the opinion that the visibility from the weather station in the direction of the accident site and at the time of the accident was at most about nine miles - the visibility being in that case obstructed by mountains at ground level and low clouds or showers at a reasonable flight level. From Flight 104s viewpoint, however, as it approached and entered the bowl (formed by the two intersecting valleys mentioned earlier), the visibility toward the Missoula Air- port at the flights apparent altitude of 500 feet above the valley floor was blocked not only by the mountains but by the showers or wall of dark clouds. Whether the captain thought, from his knowledge of the weather reports, that he would have 20 or even 40 miles visibility when nearing Missoula, and was therefore under a misconception as to the exact visibility, is a matter of conjecture. Moreover, Whether the visibility of less than 40 miles (in the direction from which Flight 104 was expected to approach the Missoula Airport) was of enough operational significance to require reporting, it is noteworthy in the interest of safety in that possible misunderstanding on the part of the captain might have existed. Flight 104 was below the clouds and on a heading toward Missoula within '6 to 6-1/2 nautical miles west of the accident site at or near an altitude level with the tops of the surrounding mountains and was descending. This would put the air- craft below 9,000 feet m.s.l., the minimum en route altitude to which it had been assigned by ATC, in accordance with his IFR clearance. Whether at this tame the flight had received its clearance to the Missoula Airport is not known; but under the assumption that it had received the clearance, it being one omitting a specific type of approach, Flight 104 was free to descend to approach altitude of 6,200 feet m.s.l. after passing the Alberton Fan Marker and proceed on to the airport. Then, if VFR flight conditions were encountered, the flight would be free to proceed m accordance therewith. The Board believes the captain knew his approximate position and was familiar with the terrain and the general course of the Clark Fork Valley leading on to Missoula, and was also familiar with the intersection of the Clark Fork and Nine- Mile Valleys. It also appears to the Board that the flight was attempting to proceed to Missoula under VFR and was descending to stay beneath the ceiling that was lowering as the aircraft approached and entered the bowl* The visibility through the airspace leading around the mountains that had to be circumnavigated in order to continue on to Missoula was reduced to the extent that instrument flight was required, The hazard involved if the flight had continued VFR around the mountains at low altitude in reduced visibility was obvious, and at that point a sharp left turn of about 90 degrees was necessary in order to proceed up the intersecting Nine-Mile Valley under VFR conditions, In attempting this turn, the aircraft was maneuvered in a manner wherein control of it was lost and the crash resulted. It is also obvious thau the pilot should have made an IFR approach in view of the mountainous terrain and the weather conditions surrounding the accident site which precluded VFR flight. Examination of the wreckage supports the conclusion that the aircraft was completely intact prior to impact. This was corroborated by witness statements, Obtained from RareAviation.com. See our selection. Copyright (c) 2004 - 7 - ----w the extensive ground search, and examination of the wreckage Moreover, the results of the exhaustive inquiry as to the existence of other air traffic in the area at the time Flight 104 was en route from Mullan Pass to Missoula indi- cated conclusively that no midair collision with other aircraft had occurred. Although the barometer had fallen .04 inches of mercury since the time the altimeter m the aircraft had been set, the error is not considered to have been harmful m this case since it was only about 48 feet and the crew apparently had visual contact with the ground. The powerplants were capable of normal operation up to the time of impact and in no way contributed to the cause of the accident, The engines were developing power at the time of impact and, although the exact amount of power being developed was undetermined, it is most probable that each engine was developing cruise-to- climb power. There was no evidence of the malfunction of any aircraft system. Probable Cause The probable cause of this accident was the failure of the pilot to continue in accordance with his IFR flight plan by attempting a WR approach during instru- ment weather conditions. BY THE CIVIL AERONAUTICS BOARD. ALAN S. BOYD Chairman 11 ROBERT T. MURPH Vice Chairman CHAN GURNEY Member G. JOSEPH MINETTI Member WHITNEY GILLILLAND Member SUPPLEMENTAL DATA Investigation and Hearing The Civil Aeronautics Board was notified of this accident at 1230, October 28, 1960. An investigation was immediately initiated in accordance with the provisions of Title VII of the Federal Aviation Act of 1958. A public hearing was ordered by the Board and held m the Florence Hotel, Missoula, Montana, on January 18 and 19, 1961. Flight Personnel Captain James R. Perkins, age 37, of Spokane, Washington, held a valid FAA airline transport pilot certificate with ratings in DC-3 and DC-4 with single and multxengine land privileges. He had a total of 11,620 flying hours with 8,070 in the DC-4 and C-54 type aircraft. The date of his last first-class medical exam- ination was September 23, I960 (no waivers). Captain Perkins1 last line check was February 28, I960; his last proficiency check was October attended a GAR refresher course on June 13, I960. Copilot Harry C. LaBart, age 36, of Bellevue, Washington, held a valid FAA commercial pilot certificate with ratings in DC-4, DC-6, and DC-7 aircraft with single and multiengine land privileges He had a total of 3,221 flying hours of which 446 hours were in the DC-4 and C-54 type aircraft. Mr LaBart1s last physical examination was a first-class type with no waivers given on October 13, I960. His last copilot proficiency check was given on June 10, I960, he was requalified in the DC-4 equipment on October 14, I960; and he attended a CAR refresher course on May 26, I960. Miss Louise Kight, stewardess, age 22, of Spokane, Washington, had been with the company since October 16, 1959. She had attended an Air Sea Rescue course on October 5, I960. Miss Ethel DeFreese, stewardess, age 24, of Spokane, Washington, had been with the company since February 27, 1959* The Carrier Northwest Airlines, Inc , is a Minnesota corporation with its principal office at 1885 University Avenue, St. Paul, Minnesota. The corporation holds a current certificate of puolic convenience and necessity granted by the Civil Aeronautics Board, and possesses valid air carrier certificates for its operations. The Aircraft N 48762 was a Douglas C-54A-DC. Date of last overhaul was May 21, I960, with a total tune on the aircraft at that date of 35,961.19. The last periodic check had been completed on October 6, I960, with a total time since overhaul of 881:55. It was powered by four Pratt & Whitney5 model 2SD13G engines with Hamilton standard propellers, model 23E5O. Specific Data Engine No. 1, TSO 1632:26, engine No. 2, TSO 73*42; engine No. 3, TSO 871 56; engine No. 4, TSO 606:32. Propeller No. 1, TSO 172:57; propeller No. 2 TSO 1614*58; propeller No. 3, TSO 269:49, and propeller No. 4, TSO 567:08. SA- 245 File No. 1-0098 CIVIL AERONAUTICS ACCIDENT INVESTIGATION REPORT Adopted: October 1, 1952 Released: October 1, 1952 CALIFORNIA EASTERN AIRWAYS, INC. AND OVERSEAS NATIONAL AIRWAYS, AIR COLLISION - NEAR OAKLAND MUNICIPAL AIRPORT, OAKLAND, CALIFORNIA, NOVEMBER 17, 1951 The Accident California Eastern Airways training flight, a DC-4, N 4002B, and Overseas National Airways training flight, a DC-4, N 79992, collided at an altitude of about 3000 feet MSL at approximately 1013,1/ November 17, 1951* Both aircraft were making simulated instrument approaches to the Oakland low frequency radio range. The three captains in the Overseas National DC-4 were killed, and the aircraft was destroyed by impact and fire. The two captains and one mechanic in the California Eastern DC-4 were not injured, but the aircraft received sub- stantial damage. History of the Flights Overseas Nationals DC-4?/ took off from the Oakland Airport at 0820. Captain Marion Harvey Click, company check pilot, was in command and aboard were Captains Hammond Garrard and Warren Oecil Gessner who were to receive their six months DC-4 instrument competency checks. There were no other persons aboard. The aircraft had been refueled with 1,229 gallons of gasoline and 11 gallons of oil; the total load was within the certificated gross weight and was properly distributed* At 0923, this flight received a clearance from the Oakland tower to make a practice range approach and to remain above 1,500 feet on the final approach to the airport. At 0935, the California Eastern DC-4?/ took off from the Oakland Airport for the purpose of a six-month instrument competency check. Captain Ralph A. Shope, company chief pilot, was in command and occupied the right seat. Captain Winfield B. Kinner, receiving the check, was in the left seat. Louis Goldberg, an upholsterer and company mechanic, occupied a cabin seat and was on board only to sew some arm rests. The aircraft had been refueled with 1600 gallons of gasoline, and the total load was within the certificated gross weight and was properly distributed. According to accepted practice, both flights conducted their training checks in the "Bay area, with all maneuvers above 3,000 feet. Both aircraft were equipped with hoods, installed on the left side of each cockpit to All times referred to herein are Pacific Standard and based on the 24-hour clock. 2/ Henceforth referred to as "Overseas, Z/ Henceforth referred to as "California. c D, , D A Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com r j o \ / prevent the pilots being checked from seeing outside The check pilots in th right seats, also perform the duties A f safety pilots, maintaining watch for other aircraft. There was also a third pilot on board Overseas who acted as an observer. Shortly before 1013, the approximate time of the accident, both aircraft approached the Oakland low frequency radio range station, which is 0.2 mile northeast from the approach end of Runway 15 of the Oakland Airport Overseas was on a magnetic heading of approximately 124 degrees inbound on the NW leg of the range; and California was homing on the range on a heading of 75 degrees M.jy Both aircraft were at an altitude of 3,000 feet. Weather conditions were good in the San Francisco Bay area at the time. The D. S. Weather Bureau reported at 1016 (three minutes after the accident); ceiling 25,000 feet, thin broken clouds, visibility seven miles, wind south four mph at Oakland. The suns bearing at 1015 was 153 degrees true, and its altitude above the horizon was 28 degrees and 27 minutes. During a short period prior to 1013, both aircraft were observed to converge without any apparent change in direction or altitude, Neither attempted to avoid collision but remained in straight and level flight, and collided approximately over the range station at an altitude of about 3,000 feet. California was at a slightly lower altitude than Overseas, and contact was made between the leading edge of the vertical stabilizer of California and the right side of the fuselage of Overseas just forward of the horizontal stabilizer. Shortly after the collision, Overseas crashed out of control on Doolittle Drive, the highway paralleling the north side of Oakland Airport. Its three pilots were killed at the time of impact with the ground. A number of persons driving on the highway close to the impact site received burns of varying degrees, and several automobiles were destroyed by fire. The top portions of the vertical stabilizer and rudder of California were torn off in the collision The aircraft was still controllable at an air speed of 160 miles an hour Immediately following the collision, Captain Shope had Captain Firmer remove the hood, As California was then south of the Oakland Airport at 2,500 feet Captain Shope requested per- mission to land on Runway 9R, the longest runway, and to have emergency equipment stand by. However, since all fire equipment was then at the crash scene of Overseas, the flight was directed to the San Francisco Air port, 12 miles away, where an emergency landing was made at 1021. Investigation Overseas struck the ground at an angle slightly beyond vertical. It did not move appreciably after impact and burst into flames immediately. Local fire fighting equipment extinguished the fire after considerable fire damage had occurred. The bodies of the three pilots were extricated, and the wreckage was removed from the highway to restore traffic. It was determined that Captain Garrard was in the left seat, and Captain Click m the right seat. Captain Gessners position could not be determined. As a result of ground impact, all four engines broke from the structure, and all four propellers and nose sections broke free of their respective engines. Both wings and the fore part of the fuselage had been exposed to considerable heat, and the rear of the fuselage was flattened. The main part of the aircraft was 1,425 feet southeast of the center of the Oakland Range Station. The entire empennage had been severed at the time of collision and fell free of the aircraft, landing 1,350 feet southeast of the range station. Inspection of Overseas* empennage, which had separated from the fuselage at a point just forward of the horizontal stabilizer*s leading edge disclosed aluminum paint marks running m the horizontal direction on the rubber de-icer boot of the fight horizontal stabilizer, starting about eleven feet in from the tip and continuing inboard to where the de-icer boot was torn free near the inboard end. The inboard portion of the leading edge of the right horizontal stabilizer was flattened. The fuselage had been struck on the right side about on a line with the leading edge of the horizontal stabilizer Blue paint marks were found on the fuselage m this area. Further examination of Overseas* rear fuselage disclosed a twenty foot length of antenna wire lodged in a tear in the side-skin at station No 920 This wire was of a stranded type and was positively identified as having come from the top antenna of California. All control cables which passed through the damaged rear fuselage area were severed by impact forces or by subsequent tearing forces damaged as the tail unit left the aircraft.^/ Two pieces of the top portion of the vertical fin from California were found 1,300 feet east from the center of the Oakland Range Station. An in- spection of California at the San Francisco Airport reveialed that the vertical tail surface was sheared off irregularly approximately 20 inches above the center rudder hinge. The dorsal fin portion was painted blue, accounting for the blue marks on Overseas. An inspection of the maintenance records of both aircraft indicated that they were in an airworthy condition at the time of take-off, and there was no indication from either flight of any malfunction prior to the collision. As stated, both carriers were conducting six-month pilot DC-4 checks, The first chase of the work consisted of practice turns, 'Stalls and other mane uve r s It was customary for such training flights to use the area in the south and southeast quadrants of the Oakland range Also a portion of the six-month check consisted of orientation, beam bracketing cone ldentifica- tion, and approach procedures Dunng these checks the hood is up to require the pilot in the left seat to fly solely by instruments The hoods installed in both aircraft were of fabric. The one in Overseas obscured the left windshield, except for its top two inches (approximately), and the left side glass except for its top six or eight inches. Californias installation covered the left windshield, except for about four inches from the center, and all of the left side glass. The safety pilot of California could see to his right, ahead, and to the left of ahead by about 45 degrees. 5/ See Attachment B, a photograph of two model DC-4s placed in the approximate relative positions as the two aircraft at time of collision. However, reference to Attachment A shows that Overseas, during the final stages of flight, was at a relative bearing of 53 degrees to the left of California, preventing its safety pilot from seeing Overseas. Overseas was making a standard range approach to the Oakland station inbound on the northwest leg (124 degrees) at an air speed of approximately 140 mph, and maintaining 3,000 feet, the initial aonroach altitude, all m accord with company procedure, The company also required an "in range check list, which was in effect for training flights This check list is read by the check pilot and the response is made by the pilot being checked. This list is: Altimeter "SET." 2 Seat belt - no smoking sign "ON." 3 Wing and prop de-icers OFF tl Cabin and cockpit heaters and galley switches "OFFr" (Not applicable.) 5. Driftmeter "CAGED and "OFF. (Not applicable.) 6. Trailing antennae "IN." (None on this aircraft.) Main Tanks "ON. "COLD." Carburetor air kJ ft tt 9. Cross feed "OFF. (None installed on N 4002B.)^/ 10. Blowers "LOW." 11. Hydraulic by-pass "DOWN. ItiwimT tt pre s sure T*UP e * 12. Hydraulic hand pump valve . "CLOSED (forward). 13. Automatic pilot servo ! "OFF. 14. Parking brake "OFF." 15. Mixtures "RICH." 16. Check magnetos. 17. Gear handle "IIP," flaps as required Captain Byron Sherrill, Overseas Chief Pilot, testified that this check is completed one or two minutes prior to arrival over th w range station on the initial approach. H further stated it required about one minute to complete this check. According to approved company procedure, at least three pilots are scheduled for training flights so that one can act as an observer. Normally, this observer stands on the navigators stool looking from the astrodome, particularly during turns and other maneuvers. He also is required at times to look from cabin windows on the left side for other aircraft. Company practice requires the flight to contact the tower, even under VFR conditions, one to two minutes prior to reaching the range station, for permission to make a simulated low approach to the airport. The Oakland Tower records revealed that Overseas was cleared to make an approach at 0923, fifty minutes prior to the accident, but no request from Overseas was received by the tower immediately prior to 1013. The captain of California testified that he was just about to contact the tower m accord with his companys practice when collision occurred. However, under existing Civil Air Regulations neither flight was required to contact the tower under VFR conditions. Zj By this is meant that the "high blower" was deactivated leaving the engine continually in "low blower." California required an ADF approach during the check flight, and at 0950 Captain Shope requested Captain Kirtner to do a "time and distance problem from the Oakland Radio Range Station. After orienting himself m relation to the range station and estimating the tune therefrom as four minutes 9 Captain Kinner took up a heading of 75 degrees holding an altitude of 3,000 feet, air speed 170 mph. As the flight crossed the range station at 1013, a rather abrupt jar was felt and California was swung about 30 degrees to its right. From his right, Captain Shope observed the other DC-4 descending at a sharp angle; he had not seen it previously. Captain Shope testified that a flight plan had been made out on the morning of November 17, 1951, which listed the names of three other captains who required flight checks; however, since these pilots were not present at the designated time, the flight departed without them. Investigation dis- closed that California had previously required a check list prior to reaching the range station, somewhat similar to Overseas but had discontinued its use sine such a procedure at that point would divert the attention of the check pilot and impair his watching for other aircraft. Also, the company did not normally require an observer to be stationed in the astrodome , but since the accident this has been required on all training flights. Statements were obtained from a number of eye witnesses to the accident. Some saw both aircraft converging, one headed m an easterly or northeasterly direction and the other in a southeasterly direction. Most witnesses were in agreement as to direction and that neither aircraft deviated from its respec- tive heading Time of observation of both aircraft varied from the time of impact to several seconds before the accident One witness, a pilot flying inbound on the southeast leg of the range, stated that he saw a C-54 (later identified as Overseas) immediately after the collision, and that it appeared to be on a heading of 120 degrees, which corresponds approximately with the inbound magnetic heading of the northwest leg of the range. Examination of the medical records of all crew members involved m this accident revealed no waivers for physical defects. Analysis Overseas was approaching the Oakland range station inbound on the north- west leg which has a magnetic course of 124 degrees. California was homing on the range station on a heading of 75 degrees magnetic. Thus, the angle of convergence was about 49 degrees; this was borne out by a detailed matching of wreckage, paint marks, cuts, and the probable speeds of both aircraft. The resulting computation confirms the above-mentioned angle of convergence. The cockpits of both aircraft were hooded on their left sides. Each carried a safety check pilot on the right. Further, the third crew member in Overseas was supposedly acting as an observer and would be normally stationed in the cabin during straight and level flight and at the astrodome during maneuvers. Since the airplane for some few minutes prior to the collision was observed to be in straight and level flight, it must be assumed that this observer was in the cabin, where his primary duty was to 6 maintain a watch on the left, or the hooded side of the aircraft, for other traffic. Although the observers field of vision supplements that of the safety pilot, it is also reasonable to assume that he would check the right side for traffic. The responsibility of the Overseas safety pilot under these conditions was to maintain a lookout ahead and to the right to avoid collision with other aircraft, since his vision to the left was greatly obscured, Since both air- craft were converging at an angle approximately 49 degrees for some period of time prior to collision, the evidence is clear that had the safety pilot been maintaining such a lookout, he would have definitely seen California on his right. As to why he did not do so, we may only conjecture that he , during a portion of the time, was in the process of going through the required cockpit check prior to reaching the range station or that he may have possibly been engaged in grading the pilot m the left seat or in other duties. Had Overseas observed California converging on its right, it would have been re- quired to give way to that aircraft .7/ As previously stated, California was on a heading of 75 degrees magnetic, which placed the aircraft to the right of Overseas. Ifaus, the safety pilot of California on the right side of the cockpit could not see more than 45 degrees to his left. As there was no observer stationed in the cabin, it is apparent that this flight, could not see Overseas as both aircraft converged on the range station. The fact that a mechanic working in the cabin of California did observe the other aircraft, but too late to alert the crew, is significant Had an observer been on duty, the accident could have been averted In fact during the final stages of convergence both aircraft could have been plainly visible one from the other had safety requirements of adequate lookout from both aircraft been adhered to. Furthermore, had both flights followed their company practices of reporting to the tower immediately prior to arrival over the range station, the tower operator might well have prevented the collision At the Oakland Airport the altitude of the traffic pattern is 1,500 feet, as established by the local authorities and approved by the CAA. Below this altitude all aircraft in the traffic pattern are under the control of the tower operator, whose duty is to assist in maintaining an orderly flow and separation of traffic. Above the traffic pattern altitude, the tower operator does not normally exercise control under VFR conditions. As both flights were on VFR flight plans they were not under control of Air Traffic Control. Thus, neither flight was under any ground control whatever at the time of collision; therefore, responsibility for preventing collision in this case was vested solely m the flight crews. 7/ Civil Air Regulations Section 60.14 (b) Converging. Aircraft con- verging shall give way to other aircraft of a different category m the follow ing order When two or more aircraft of the same category are converging with approximately the same altitude, each aircraft shall give way to the other which is on its right. 8/ Civil Air Regulations Section 43.67 (c) Simulated Instrument Flignt. Aircraft shall not be flown under simulated instrument flight conditions unless* (c) Such safety pilot at all times has adequate vision forward and no either side of the aircraft, or a competent observer occupies a position in the air- craft so that his field of vision adequately supplements that of the safety pilot Obtained from RareAviation.com. See our selection. Copyright (c) 2004 The Board has stated in reports of previous air collisions that pilots are charged with the highest degree of responsibility in maintaining a lookout for other aircraft. In fact, the Board7s regulations require the utmost pilot vigilance at all tunes, and CAA standards, as published in its Flight Informa- tion Manual, set forth in part that: When flying in Visual Flight Rule weather conditions, (regardless of the type flight plan or air traffic clear- ance), it is the direct responsibility of the pilot to avoid collision with other aircraft," It appears that the hoods installed m both aircraft met the general requirements of the CAAs Manual of Procedure, No, 4-2-1 Ihis reads m parts "The applicant for an instrument rating will furnish a certificated aircraft suitably equipped wixh a proper hood, baffles, cr colored glass, * "The term proper hood5 is construed to mean a hood, which will completely exclude all outside visual reference to the pilot on instruments yet not unduly restrict vision of the safety pilot, agent, or examiner Sufficient visibility to permit clearance for turns in either direction, as well as adequate forward visibility is required. In aircraft having a side-by-side seating arrangement affording inadequate visibility to tne left, a safety observer will maintain a watch on the lefr Such observer must b c in > J uninterrupted aural or interpnone contact with the safety pilot at all times." Overseas, following this accident^ continued to use the same type of hood. The company believes that this type hood offers a satisfactory degree of safety because it permits a reasonable amount of vi sion to the left by the safety pilot a "Bie company further feels that uhen "Bie company further feels that when a competent observer IS carried^ as was the tA.'hAn -Hti nnl lisi nr? r r? case when this collision occurred, rhe re is ample vision ahead and no both sides, The fact rhat Overseas was hooded did not in any way contribute to the accident Overseas is continuing to use a check list prior to arrival over the range station on the initial approach Company policy is to complete this check-off at an appreciable period of time before arrival over the range. Following the accident the CAA recommended that both carriers adopt a different crew arrangement during training flights This called for the safety pilot m the ^ignt seat mo have no other duty than keeping continuous watch ahead and to both siaeso The engineers (jump) seat would be occupied by the cheek pilch who would accomplish grading the trainee and handling the cneck-off. However, Over- seas continued using its former crew arrangement except that the observer is now stationed continuously at the astrodome; this arrangement was acceptable to the CAA. California, immediately after the accident, revised its policy to re- quire that the third crew member or observer on all instrument training flights be stationed at the astrodome. It also changed its type of hood installation, using a vertical slat or baffle type hood, which permits a largely unobstructed field of vision to the lefr by the safety pilot. Later, following the a fore-mentioned recommendation by the CAA., California again revised its crew arrangement, complying with that recommendation in full. On January 3, 1952, the CAA filed a report of violations of the Civil Air Regulations against the safety pilots of both aircraft. Captain Click, (deceased), safety pilot of Overseas, was charged with three violations of the CAR^2/ These are summarized in the violation report, to wit: "While on a six months hood check the safety pilot and third crew member acting, it is assumed, as another observer for aircraft, failed to see the California Eastern C-54 and collided with it." Captain Shope, safety pilozt of California, was likewise charged with three violations of the CAR.12 These are also summarized in the violation report, to wit: "While under an instrument hood during a six months hood check, the safety pilot sitting m the right hand pilot seat failed to provid a third crew member to supplement adequately the restricted vision of the safety pilot." The CAA filed these violation reports for record purposes only. Both the Board and the Administrator, in conjunction with the industry and the military, have had the over-all problem of airspace collision hazard under intensive study for some time, including the function of airport traffic control under VFR conditions. Concerning the latter, the Board is considering a requirement that all simulated instrument (hooded) flights operating in accordance with visual flight rules be under tower supervision at all times when within the airport control zone. Irrespectivo of the lack of tower supervision, however, it is clear to the Board that had the responsible crew members of both aircraft complied with existing Civil Air Regulations and maintained the lookout required, this accident would not have occurred. Findings On the basis of all available evidence the Board finds that: 1. Both carriers, both aircraft and all five pilots were properly certificated. 2. Both flights were operating under visual flight rules from the Oakland Airport. 3. Both flights were for the purpose of giving six-month instrument competency checks, with hoods installed on the left side of both cockpits 4. Overseas carried an observer, as required^ California did not 5. Both aircraft were making simulated (hooded) instrument approaches to the Oakland range station at the same altitude. 9/ These are CAR Sections 60.12 (c), 60.14 (b) and 60.15 10/ These are CAR Sections 43.67 (c), 60.12 (c) and 60.13. 6 The aircraft converged at an angle of approximately 49 degrees# 7 Overseas was a few feet higher than California 8 No evasive action was taken by either aircraft before collision 9. Collision occurred at an altitude of 3,000 feet approximately over the Oakland range static: Probable Cause The Board determines that the probable cause of this accident was the failure of the Overseas safety pilot and/or his observer to observe and so avoid the other aircraft and the failure of Californias safety pilot to carry a qualified observer aboard the aircraft to insure an adequate field of vision BY THE CIVIL AERONAUTICS BOARD: DONALD W. NYROP s/ OSWALD RYAN s/ JOSH LEE /s/ JOSEPH P. ADAMS CHAN GURNEY SUPPLEMENTAL DATA Investigation and Hearing The Civil Aeronautics Board received notification of the accident on November 17, 1951, at approximately 1100, by telephone from CAA Communications Los Angeles, California, and immediately initiated an investigation in accordance with the provisions of Section 702 (a) (2) of the Civil Aeronautics Act of 1938, as amended. A public hearing was ordered by the Board and held at Oakland, California, on December 13, 1951. Air Carriers California Eastern Airways, Inc., was incorporated under the laws of the State of Delaware m 1946 and operated as an exempted air freight carrier until 1948. On August 1, 1950, the company was granted a prime contract by MATS (Military Air Transport Service) to fly passengers and, or, freight on the Pacific Airlift over routes designated as "Mid Pae" and was engaged m this operation on November 17, 1951. The company holds Letter of Registra- tion No. 0-14 of the Civil Aeronautics Board, dated October 3, 1947, and was issued an air carrier operations certificate No. 6-10 (c) on February 19, 1951. Overseas National Airways, Inc., was incorporated under the laws of the State of Delaware m 1950. The company was issued Letter of Registration No. 806 by the Civil Aeronautics Board on August 12, 1947, but since the carrier's aircraft were being operated by Transocean Air Lines, under agree- ment, the Letter of Registration was cancelled. However, after Overseas National obtained control of its aircraft, it applied for, and the Board re- issued, the Letter of Registration on April 25, 1950. The company was also issued air carrier operating certificate No. IR-5 by the Civil Aeronautics Administration on September 12, 1947. This carrier also has a contract with MATS (Military Air Transport Service) to fly passengers and/or freight m air lift operations. Flight Personnel Captain Ralph A. Shope, age 40, was employed as chief pilot by California Eastern Airlines, Inc., on March 3, 1951- He started flying m 1934 and sub- sequently instructed Army cadets; later he flew for TACA, TWA-ATC during World War II and for KLM and SAS until March 1951, acting as pilot and pilot navigator. His total flight time on November 17, 1951, was approximately 11,225:20 hours, of which 4,732:59 hours were in DC-4 aircraft. His total instrument time was 1,005:55 hours. Captain Shope held a valid airline transport pilot and flight instructor certificates, and had passed his last physical examination on September 6, 1951. Captain Winfield B. Firmer, age 40, was employed by California Eastern Airlines on August 1, 1951. His flight training started m 1928. He was a pilot instructor for the U. S. Air Force m 1943 and subsequently flew for ATC and other military services. During 1950-51, Captain Kinner was a pilot for several irregular air carriers. His total flight time on November 17, 1951, was 5,000 hours, 3,500 of which were in DC-4's. His total instrument time was approximately 350 hours. He held a valid airline transport pilot and flight instructor certificate, and had passed his last physical examination May 1, 1951. Captain Marion Harvey Click, deceased, 31, Overseas National Airways assistant chief pilot was employed by the company on June 16, 1950, as a captain, He received his early flight training in the U. S. Air Force and thereafter as pilot and captain for several air carriers. His total flight time was 7,871 hours, of which 5,028 hours were m DC-4 His total in- strument time was approximately 617 hours. Captain Click held a valid airline transport pilot certificate, and had passed his last physical examination on July 13, 1951. He also held a letter of authorization from the Civil Aeronau- tics Administration to act as company check pilot. Captain Warren Cecil Gessner, deceased, age 27, was employed by Overseas National Airways on June 16, 1950, as a first officer, and promoted to captain on December 4, 1950 He had received his flying training in the U. S. Navy and later with Alaska Airlines, Near East Transport, and Westair Transport. His total flying time was 3,590 hours, and approximately 1,900 hours were m DC-4 aircraft. Captain Gessners total instrument time was 652 hours. He held a valid airline transport pilot certificate and had passed his last physical examina- tion on May 7, 1951. Captain Hammond Garrard, deceased, age 32, was first employed by Overseas National Airways on July 6, 1950, as a first officer, and was promoted to captain on July 17, 1950, but was furloughed until November 15, 1950o His flight training was obtained in the U. S. Navy; later he piloted for California Eastern and with Capital Airlines. He had a total of 5,879 hours and 3,100 hours of this time was m DC-4 aircraft. His total instrument time was 330 hours. Captain Garrard held a valid airline trans- port pilot certificate and had passed his last physical examination on May 14, 1951. The Aircraft N 4002B was a DC-4, and as of November 16, 1951, had a total of 16,435 hours. Flight time since its last overhaul was 6,484 hour; All historical and maintenance records pertaining to the aircraft were found in order* California Eastern Airways had leased N 4002B from TACA Airlines on April 5, 1951. N 79992, also a DC-4, had a total time of 5,257 hours since last overhaul. The aircraft was obtained by Overseas National Airways from the U. S. Air Force on a lease agreement dated May 2, 1947. It was subsequently sub- leased to Transocean Airlines, but this lease was later terminated on January 9, 1950. The aircraft was first operated by Overseas National Airways on August 16, 1950. - ii - 2 33 miles Distance and Closing Diagram Path of Overseas Air Collision of 2 DC-4s Speed 140 m ph 78 Oakland Calif , Airport Nov 17. 1951 124 M I 16 miles , 58 miles o C / / (A. 715 miles Impact Site 75 M App 3000 feet I 43 miles above Oakland Range Station 53 Path of Coliforma Speed 17 0 m p h Mtachment A 2 86 miles 13786 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: October 20, 1947 Released: October 21, 1947 PAN AMERICAN AIRWAYS, INC ---NEW ORLEANS, LOU 1 SI ANA---DECEMBER 19, 19U6 The Accident Captain Sidney A. Adger, the pilot, Pan American Airways Flight 702. NC- called Moisant Tower after crossing the 88897, a Douglas DC-4, collided wi th Barataria marker, reporting that he had trees m the immediate vicinity of Moi- flown over the marker at 2151, and that sant Airport, New Orleans, Louisiana, at he was then on instruments at 1,000 feet. approximately 2258/ December 19, 1946. In response, the tower transmitted a Considerable damage resulted to engines 2100 Moisant weather observation which and aircraft, but no injuries were sus- was* "Ceiling 2,700 feet, scattered tained by any of the 45 occupants. After clouds at 1,400 feet, visibility 4 the accident the aircraft proceeded to miles." The tower then cleared the Brookley Field, Mobile, Alabama, landing flight to land on Runway 10 at the cap- safely at 0105, December 20, 1946- tains discretion, and stated that the altimeter setting was 29.93 inches. History of the Flight Flight 702 reported over the New Or- Flight 702 originated at Balboa, Ca- leans range station at 2J57, made a standard instrument "let-down" on the nal Zone, December 19, J946, and made northeast leg of the range, and after routine stops between Balboa and Guate- passing the range station, flew a head- mala City, Guatemala, where the crew of ing of 280 degrees toward the field. The six involved in the accident boarded and aircraft passed over the Moisant Airport assumed control. No difficulty was to the right of Runway 10 "contact." A experienced from Guatemala City to Meri- left procedure turn was then made for a da, Mexico. Departure from Merida was at landing into the wind on Runway 10. Cap- 2103, December 19, 1946, with 39 passen- tain Adger, however, was unable to align gers, the crew of six, and 2,000 gallons the aircraft with the runway, and was of fuel aboard. The company cleared the obliged to climb, and to proceed again flight direct to New Orleans on an in- out the northeast leg of the range. At strument flight plan at an altitude of approximately 2218 the flight passed 8,500 feet, Lake Charles, Louisiana, and over the range station, in-bound for the Mobile, Alabama, being designated as second approach, Captain Adgers second alternates. Good weather was expected pattern being substantially the same as along the entire route, and no difficul- his first. At about that time the 2218 ty anticipated for the landing at Moisant weather observation was transmitted by Airport, New Orleans, Louisiana, however, the tower. This observation was*"Indef- instrument conditions were expected in inite overcast, indefinite ceiling, 400 the vicinity of New Orleans. overcast 200 scattered, moderate rain, Two hundred miles from destination light fog, Visibility' 2^/2 miles." A Flight 702 was flying "contact.' At that landing at this time was not completed time the New Orleans airway traffic con- because visibility was obstructed by trol center (ATC) cleared the flight to the Moisant Tower, and instructed it to heavy ram. Captain Adger climbed to an cross the Barataria fan marker, which is altitude of 500 feet, and held a heading approximately 20 miles south of the New of 100 degrees for a period of one min- Orleans range station, at 1,500 feet or ute. From that time on until the land- ing at Brookley Field, Mobile, Alabama, below. At 2132 the flight was advised there is no reliable evidence of record by Overseas-Foreign Airways Communica- from which the exact flight path of tion Station, New Orleans, that the barom- Flight 702 can be determined. Shortly eter at New Orleans was falling rapidly. after Captain Adger completed his second All times to herein are Central Standard approach, the tower transmitted the fol- Time ano base^ on the 24-hour clock lowing 2228 weather observation. --- 17665 (1) Obtained from RareAviation.com. See our selection. Copyright (c) 2004 "Indefinite 200 overcast, lower scat- and vibration. Clearance to Mobile at tered, visibility 2, heavy rain, light an altitude of 2,000 feet or below fog, temperature 51, dew point 51, wind was given by ATC, ana Captain Adger was east at 12, altimeter 991, indefinite advised that Brookley, the Army Air 400 foot overcast, ceiling ragged."1 Force Field, Mobile, had crash equipment Between 2228 and 2240 Flight 702 was and would be a suitable field for land- advised that the Pan American dispatcher ing. Biloxi, Mississippi, (Kessler Army at Brownsville recommended Memphis, Ten- Air Field), raidway to Mobile, was re- nessee, as an alternate, and the tower porting a ceiling of 1,000 feet, and. related to the flight information con- visibility of 2 miles at the time that cerning course and distance to Memphis, 702 was m the vicinity. Captain Adger which Captain Adger had requested. At continued on. After arriving over Brook 2243 the tower transmitted the following ley Field, Flight 702 circled the tower weather observation "Indefinite 300 to have a visual check made of the land- overcast, lower broken, visibility 2, ing gear. A landing was accomplished at light ram, light fog, barometer falling Brookley at 0105, December 20, 1946, rapidly, altimeter 985." At approxi- without further difficulty. mately 2251 Flight 702 reported holding at 2,000 feet between New Orleans range Investigation station and a point 4 miles northeast. Examination of the aircraft, NC-88897, At 2258 the tower transmitted the fol- indicated that considerable damage had lowing weather observation "Ceiling 300 resulted from the airplane fly ing through feet broken, visibility 2, light rain, trees on the third approach at New Orle- light fog, altimeter setting 981. ans. Spanish moss and wood particles Sometime between 2228 and 2303, Flight were found in Nos. 1 and 2 engine na- 702 made a third approach for landing at celles, runway. with trees. The flight then proceeded to Mobile, Alabama, and landed safely. Findings Probable Cause On the basis of all available evi- dence the Board finds that: The Board determines that the proba- ble cause of this accident was the pi- 1. The aircraft, crew, and carrier jots deliberate descent through an were properly certificated. overcast to a dangerously low altitude 2> Weather data and charts available in an attempt to land despite his knowl- to the crew prior to departure fromMeri edge that ceilings and visibility were da, Mexico indicated that good weather below the minimums authorized by the existed along the route , but that instru- Civil Aeronautics Administration. meat conditions would be encountered m the New Orleans area, and that weather BY THE CIVIL AERONAUTICS BOARD: conditions similar to those in New Orle- ans could be expected at Lake Charles Isl J. M. LANDIS 1st OSWALD RYAN and Mobile. /st JOSH LEE 3. Lake Charles and Mobile, both m the same storm area as New Orleans, were Branch, Member did not take part in designated as alternate airports. the decision. ---17665 c D. , D Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAvicftion.com rx 7 I At the time ol the accident he had logged 3,146 hours, 1,000 hours being in. DC-4 No notification of this accident was equipment, and 350 hours being instru- given by Pan American Airways to the ments. Captain Adger held an airline Civil Aeronautics Board. First knowledge transport rating. Certificate No.162003. >as received from the Chief, CAA Air He had been given a route check into Carrier Inspector for the Second Region Moisant Field, nowever, he was not fa- who informed the Boards Investigator^ m miliar with any of the designated alter- Charge at Atlanta, Georgia, that Pan nate fields for Moisant Airport. Nicholas Anericans Flight 702 nad met with an H. Lutz, the co-pilot, age 30* was em- incident*. Full particulars were re- ployed by Pan American January 4, 1943. quested by telegram. On December 23, He held an airline transport rating, 194b, the Operations Manager for Pan Certificate No. 129485- When hired, he American Airways in Miami submitted had a total of 1,500 hours accumulated information to the Civil Aeronautics m the U* S. Army Air Corps, and at the Board, Atlanta office, that Flight 702 nad struck trees while approaching Moi- time of the accident he had logged 2,926 sant Airport for a landing, and that the hours, 162 m DC-4 equipment, and 370 hours instruments. Both pilots received damage resulting was extensive enough to a CAA physical examination July' 16* 1946. hive replacement parts sent to Mobile Other crew members were: C. A. Doles, where the aircraft had landed. An inves- Flight Radio Officer, A. Garcia, Purser, tigation wa$ initiated immediately m M. I. Dewey and P, OBrien, Steward- accordance with the provisions of Sec- esses . tion 702(a)(2) of the Civil Aeronautics The captain and first officer were Act of 19381 as amended. properly certificated for their respec- A public hearing was ordered by the tive duties, and the captain was quali- Board and was held at Miami, Florida, fied over the route. February 10, 1947. At Carrier Aircraft Pan American rtorld Airways, incorpo- NC-88897, a Douglas DC-4, was acquired rated under the laws of Delaware and by Pan American Airways from the military having established its headquarters in services and was converted for commer- New York, New York, with bases at Miami cial use at the Douglas factory on June and New Orleans, was operated under a 25, 1946. It had accumulated a total of certificate of public convenience and 4100*39 hours, 1436 52 of which were necessity and an air carrier operating since conversion. certificate, both issued pursuant to the Four Pratt & Whitney R-2000-11 en- provisions of the Civil Aeronautics Act gines, equipped with Hamilton Standard of 1938* as amended. These certificates propellers, were installed. authorized Pan American World Airways to Total time on No.l engine was 2196*28 transport persons, property, and mail hours. between Balboa, Canal Zone, and New Or- Total time on No.2 engine was 1834 40 leans, Louisiana. hours. Flight Personnel Total time on No.3 engine was 2439 46 hours - Captain Sidney A. Adger, age 30, was Total time on No.4 engine was 1530.35 employed by the Pan American Airways May hours. 5, 1941, having a total of 205 hours Total time on each engine since over- accumulated in the U. S. Army Air Corps. haul was 63.31 hours ---1^665 (n Obtained from RareAviation.com. See our selection. Copyright (c) 2004 SA-151 File Ko. I-00<3 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: March 29, 1948 Released: March 30, 1948 ---.............. * PAN AMERICAN Al RWAYS---FLOYD BENNETT FIELD, BROOKLYN, NEW YORK- SEPTEMBER 20, I9U7 The Accident minutes later Mr Robinson noticed that tne right auxiliary fuel gauge indicated Pan American Airways Flight 131, a C-54-DC airplane, NC-88911, executed an not 40 gallons, but 100, and that it was emergency landing at Floyd Bennett Field, visibly increasing even though no fuel Brooklyn, New York, at approximately was at that time being transferred The 1823,1 September 20, 1947 No injury was No. 3 mam fuel tank gauge then dropped sustained by any of the 41 persons on to zero, and the fuel pressure for the board The aircraft, however, received No 4 engine started to fluctuate. major damage Alarmed by what now appeared to be a serious malfunction in the right side of History of the Flight the fuel system, Mr Robinson operated all engines from the left main tanks (1 Pan Americans Flight 131 departed from Bermuda at 1358, September 20, 1947, and 2), turning on all the cross feed valves, and the booster pumps for main with 36 passengers and a crew of 5. The tanks 1 and 2 take-off and climb to the cruising alti- The flight had by this time reached tude of 8,000 feet were normal, and the position "Baker," a point on course and flight proceeded on course to LaGuardia a distance of 212 statute miles from La- Field, New York, for a period of 3 hours Guardia This check point was regularly without incident Between 1650 and 1655, used by Pan American on the route from about 225 statute miles from destination, Bermuda to LaGuardia, and was established Warren Robinson, the first officer, no- by reference to precomputed radio bear- ticed a fluctuation in fuel pressure for ings Flight Radio Officer Rea was in- engines 1 and 2 Seconds later, the left structed to call Captain C&rl Gregg, who auxiliary fuel tank quantity gauge was eating lunch in the passengers cabin, dropped to zero, the fuel pressure warn- to the cockpit. The captain, unable to ing light flashed on, and the No 1 en- account for what appeared to be a total gine faltered To insure a positive fuel loss of fuel in the right main tanks, supply for all engines Mr Robinson im- tried to operate engines 3 and 4 from mediately turned the fuel selector valves their respective mains. Shortly after, for all engines to their respective main the fuel pressure for both these engines tanks, following which all engines op- dropped, the fuel pressure warning lights erated normally. came on, and engines 3 and 4 lost power. Mr Robinson then transferred fuel Other combinations of fuel valve settings from the right auxiliary tank to the left were tried during the next fdw minutes, auxiliary tank so that they would contain but power could not be restored to en- equal amounts, which was 40 gallons eaich gines 3 and 4 The "fasten seat belt" according to the fuel quantity gauges sign was turned on, rated power was ap- after completion of the operation A few plied to engines 1 and 2, and a descent of 200 to 300 feet per minute started. All llines referred to herein are Lastern Standard Two minutes later the fire warning an^ based on the 24-hour clock. light flashed on for engine 4 The flight One main tank is installed In the C-54 for each radio officer was sent to the passengers engine and is numbered so as to correspond to the en- gine, i e , No 1 main tank is located in the wing panel cabin to see if any signs of fire from next to and normally feeds the No 1 engine In addi- this engine were visible He saw none tion to these 4 main tanks, there are 2 auxiliary tanks, one in the left and one in the right wing panel For from engine 4, but he did see smoke trail further detail see the chart. Appendix I, attached to ing from engine 3. By the time Mr Rea this report --- 18824 ^1) returned to the cockpit, Captain Gregg tacted. This was NMR, the Coast Guard noticed the smell of burning rubber, and station in San Juan, Puerto Rico. Even furthermore, that the fire warning light this contact was not entirely satisfac- for engine 3 was also on. No flames from tory, and no radio bearing from it was either engine, however, were visible. ever received. The radio equipment was Standard fire fighting methods were fol- accordingly returned to the frequency of lowed to control the fire in the No. 3 8565 kcs , the established channel of nacelle. The propeller was feathered, communication, for further radiophone all fluids into the engine were closed at contact with New York. No call was ever the emergency shutoff valves, and the CO2 made on the international distress fre- gas bottle was discharged. The fire quency of 500 kcs., or over any of the warning light then went out. Since there "VHP" equipment on board. was no visible indication of fire in en- By 1800, altitude had been lost to 800 gine 4, the CO2 gas bott'le was not dis- feet, and still over 50 statute miles charged. As a precautionary measure, remained to destination. Preparations however, the shutoff valves for all were made for "ditching." The passen- fluids into the engine were closed, and gers were instructed in the use of life an attempt made to feather the propeller jackets, and in emergency water landing But, the propeller would not feather, and procedures. The life rafts ,were moved continued to windmill. so as to be easily accessible from the At 1712, shortly after Mr. Rea trans- main cabin door. Celluloid protective mitted to the company the flights po~ coverings were removed from all the emer- sition as "Baker," a loud noise from the gency exit handles Clothing was loos- right side of the airplane was heard, and ened, and seat belts tightened. Flight simultaneously the green right landing Radio Officer Rea broadcasted "blind" on gear lignt came on. Through the drift the frequency 8280 kcs., reporting the sight the crew could see the right out- position of the flight to be 40-00 de- board tire burning, and a landing gear grees north and 73-10 degrees west. From bungee cable hanging slack. All attempts this point on only a small gradual loss to raise the right gear were unsuccess- of altitude was experienced. Captain ful, and it was found that with the right Gregg decided to attempt to reach and gear down, and with both right engines land at Floyd Bennett Field, and was ad "out" that an air speed of 125 miles per vised through Eastern Air Lines radio hour was required to maintain directional that runway one would be available. control. At 1730, engine 4 stopped wind- New York Air Traffic Control had been ill Ing, having seized from lack of alerted through Eastern Air Lines radio lubrication By 1745, altitude had been of the emergency, and they in turn had lost to about 1,000 feet, and over 100 called Coast Guard search and rescue. statute miles remained to destination, Coast Guard, Army, and Navy rescue equip* Full take-off power was applied to en- 11 ent was dispatched, and as Flight 131 gines 1 and 2 in an attempt to hold the approached the coast, the crew observed remaining altitude. other aircraft and surface vessels pro- A report had been transmitted to the ceedlng out to meet them. At 1815, ap- company at 1729 that the fires in engines proximately 15 statute miles from Floyd 3 and 4 were believed to be out, and at Bennett Field, the flight had descended 1740, the company had been advised that to an altitude of 400 feet. Full avail- the flight was at 2,000 feet still de- able power was now applied to engines scending All radio contacts with Pan 1 and 2, and the flight was able to not American at LaGuardia throughout the only hold, but even gain a slight amount course of this emergency were accomplished of altitude. Four to fi*ve minutes later, through Eastern Air Lines1 radio on the 1820, throttles were retarded to take-off frequency 8565 kcs. Mr. Rea attempted power and the aircraft maneuvered into a to secure a fix on "CW"^ from the U. S. position for a stralght-in landing ap- Coast Guard, using the distress frequency proach on runway one. of 8280 kcs. Because of an extreme The aircraft was set down 775 feet amount of "CW" interference on this fre- from the south end of runway one, wheels quency only one station was actually con- up* During the course of the crash land- ing the No. 1 propeller was torn from CVi"---Abbreviated for continuous wave transmission the engine, the propeller dome becoming of code rather than voice embedded in the No. 2 main fuel tank. --- 18824 The spilled gasoline was ignited by No irregularities were found in the sparks generated as the airci aft skidded fuel system, except those which had re- 2,167 feet on the concrete runway to a sulted from fire m the air in the No. 3 stop U. S. Navy fire and crash equip- nacelle Otnerwlse, all lines, strainers, ment had been previously deployed along hose connections, pumps, and valves were runway one which allowed the Navys crash found clean and in good condition. Fuel personnel to bring the fire quickly under from all tanks was drained and measured control, and to assist the passengers and The No. 1 main tank contained 150 gallons crew to deplane without injury. No. 3 main 125, No. 4 main 335, the left auxiliary 28, and the right auxiliary 7 Investigation gallc. is No fuel was found in the No. 2 C ons ide r ab le damage to the aircraft main tank for the reason that this tank resulted from the crash landing and the had been broken open during the course fire which followed. The fabric on the of the crash landing by the dome of the rudder and elevators was burned off, and No. 1 propeller a portion of the left wing panel, includ- Engines 3 and 4 were sent from Floyd ing the No. 2 fuel tank, was also de- Bennett Field to the Pan American Latin- stroyed by fire. The underside of the American base at Miami, Florida. No fuselage, the engine cowlings and oil part of engine 3 was disturbed from the cooler scoops, the wing flaps, and the engine mount forward other than removing landing gear doors were torn and scraped the generator for study at the National from contact with the runway. All blades Bureau of Standards, and changing the on propellers 1 and 2 were scuffed and damaged propeller for a test one, which bent. Two blades on 3 were scuffed, and was installed at Miami. This engine, the tip of one blade on 4 was slightly when mounted on a test stand in Miami, bent The nose section of engine 1 was was started and operated without diffi- torn completely from the rest of the en- culty. The No. 4 engine had been so gine. Damage w.iich occurred prior to the damaged as a result of windmilling with- crash landing was confioed to the No. 3 out lubrication that disassembly was nec- engine nacelle, the right landing gear, essary. Excessive damage was found to and the No. 4 engine. have resulted in the rear power section, The C-54 has mounted forward of the but no indication of any malfunction or front wing spar (zone 3) in engine na- failure was found which occurred prior to celles 3 and 4 a battery "bus,"4 a solid the time that the flow of oil to the en- electrical line of 5/8" aluminum covered gine was stopped by Captain Gregg at the with fire resisting fabric insulation. shutoff valves. Electrical components including volt- Below this "bus," also mounted on the age regulators, reverse current relays, front wing spar in the No 3 engine na- celle is a magnesium engine control pulley generators, and batteries were examined, bracket. In NC-88911 at a point directly and tests were also conducted by the above the pulley bracket, the battery National Bureau of Standards. All elec- "bus" had melted in two from electrical trical components, with the exception of arcing. The bracket also had burned and the No. 1 generator which was "out," ap- melted from electrical arcing, and many peared to be normal. of the engine control cables which it Because of the apparent origin of the held had been fused together. From this fire---the electrical arcing between the particular area to all points within zone battery "bus" and the engine control 3 of this nacelle, there was evidence of pulley bracket---tests with like materials fire.5 The aluminum conduit which carried were conducted in Miami by Pan American the magneto ground leads for engines 3 and CAA personnel. A 3-foot piece of and 4 was burned in two, part of the in- 5/8" aluminum was energized with an sulation was destroyed, and tije magneto electrical current of 400 amperes and 28 ground leads for engines 3 and 4 grounded. volts to simulate the "bus." It was then Many other electrical lines had been brought in contact with a section of either burnt in two or grounded. magnesium alloy which was grounded and of This "bus* connects all four generators to the bat- a mass 1 5 times that of the pulley bracket found in NC-88911. Tne first teries See Appendix II for diagrams of this installa- contact was made intermittently, which tion. resulted in a considerable amount of 9A detailed report of the damage found In zone 3 of engine nacelle 3 will be found in Appendix XII of this arcing. Melted particles of magnesiu II report ---10824 dropped and burned until consumed. The corrective action to eliminate the possi- "bus" bar was then held in firm contact bility of "bus" bar trouble m the C-54fs< with the magnesium It was found that, Maintenance and historical records of except for an initial small arc, no burn- NC-88911 were carefully examined. All ing of the magnesium took place The entries including pilot complaints ap- parts welded together The third test peared routine, however, several entries consisted of adjusting the aluminum and had been made in the aircraft log to the magnesium pieces so as to maintain a con- effect that the aircraft vibrated exces- tinuous arc When so adjusted, the arc- sively during climb There is a possi- mg resulted in rapid erosion of both the bility that excessive vibration may have aluminum and the magnesium, however, the contributed to the electrical arcing be- main body of the magnesium did not ignite tween the "bus" ahd the engine control except for small areas which were ad- pulley bracket m this case. Jacent to the arc The last test con- It was found that all members of the sis ted of dropping pieces of control cable crew were qualified to make the flignt over the energized "bus*" from Bermuda to New York. Captain Carl An inspection of nacelles 2 and 3 in Gregg, age 36, had a total of 9,758 fly- other C-54 airplanes revealed in a few ing hours, 1,800 of which were m C-54 cases a chafed condition of the insulation equipment. He had accomplished a ground on the "bus" in the vicinity of the en- school course m the operation of the gine control pulley bracket which had not C-54, and had, during his period of em- been previously suspected. Such a chafed ployment with Pan American, successfully condition, where the clearance between completed training as a navigator. Train- the "bus" and the bracket was small, ing in navigation consisted of a ground created an obvious hazard of arcing and school course averaging,approximately 200 fire Accordingly, the clearances be- hours, and covered celestial and dead tween this bracket and "bus "were examined reckoning navigation, cruise control, m C-54s, operated not only by Pan star identification, and other related American but also by other carriers, It subjects. After completing several was found that the clearances varied from flights, the principal duty being navi- 1/16" to 2" A few carriers had protected gation, Captain Gregg was qualified by the "bus" by a metal conduit or a rubber the company as a navigator as well as a s hield pilot. He satisfied the company require- Further examination of nacelle 3 in ments that the captain of any flight over NC-88911 revealed that the support for water be a qualified navigator as well as the "bus" inboard of the engine control pilot. pulley bracket was a piece of fabricated Warren R Robinson, age 27, the co- dural not standard with the Douglas manu- pilot, had a total of 3,456 hours in the factured product, and of thinner material air, of which 200 hours were in C-54 than that found in the No 2 nacelle of equipment. Mr. Robinson had also accom- the same airplane It is not known when plished a ground school course in the or by whom this "bus" support in nacelle operation of the C-54 as well as flight 3 was installed. Furthermore, this sup training in the airplane. Though he had port, and similar supports in this par- not completed the course in celestial ticular model of C-54s, held the "bus" navigation, Mr. Robinson had accomplished closer to the face of the spar and the the training offered in dead reckoning engine control pulley bracket than was navigation. true in later models. Notice through the All members of the crew, including the Air Transport Association was sent to radio officer, purser, and steward, had operators of C-54s describing the con- been given training in emergency proce- dition found in NC-88911, which provided dures and "ditching." Each crew member the operators with an opportunity to in- knew and performed his duties m a calm spect their aircraft and perform the nec- and efficient manner. essary preventive maintenance. On October Radio direction finding stations, 31, 1947, the Administrator notified all operated by the Coast Guard prior to the field offices that an inspection of the close of the war, are now maintained only bus installation in the C-54 was manda- In a caretaker status. Their function tory. This action was followed by the has been assumed by the Federal Communi- issuance of a CAA Airworthiness Directive cations Commission. Since the FCC, how- which required further inspection and ever, is primarily a law enforcement ---18824 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 Accident Investigation Report 5 agency, it is not able to Rive as co II. promptly relayed through Eastern Air plete a service to aircraft in distress Lines* radio to Pan American and CAA Air as that which was previously rendered by Traffic Control. All information re- the Coast Guard. ceived by Air Traffic Control was relayed A representative of the United States to Coast Guard search and rescue, and Coast Guard was asked for his recommen- available facilities for rescue were dation as to how best alert search and promptly and efficiently dispatched. rescue facilities. He stated- that under The weather which existed during the present conditions the most efficient time of the flight is not considered a means was to use any channel of radio factor in this accident. A large high communication established at the time of pressure area was centered over New the emergency. The International emer England, and a cold front crossed the gency frequency 500 kcs., though guarded flight route at approximately 34 degrees by all surface vessels, is of limited use north In the frontal zone were scat- since its range is relatively short tered thunderstorms and towering cujnulo- .Furthermore, to utilize fully that fre- nimbus clouds. The flight had progressed quency it is necessary to use a trailing beyond this frontal area at the time that antenna. The carrier in this case be- trouble was experienced, and only scat- lieved the difficulty of handling in tered clouds were encountered from that flight a trailing antenna offset any ben- time until the crash landing at Floyd efit which might be received from its Bennett Field. use. Much greater range is possible on 8280 kcs. than on 500 kcs., and it is some- sscussson times used by aircraft of United States As stated above, no irregularities registry for distress calls However, no were found in the fuel system other than international agreement exists setting those caused by fire in the No 3 nacelle. this particular channel aside for dis- It was impossible to make an accurate de- tress. Though limitations have been set termination of the quantity of fuel con- as to the use of 8280 kes by the Federal tained in the left auxiliary tank prior Conununications Commission, and notice of to take-off from Bermuda, but the testi- the limitations given to foreign govern- mony of the co-pilot indicated it to be ments by the State Department, surface sufficient for about 10 minutes of flight. vessels and aircraft, particularly those Tne only possible cause of fuel pressure of foreign registry, use 8280 kcs. as a fluctuation in engines 1 and 2 was ex- calling frequency. In the present case haustion of fuel in the left auxiliary the radio operator was confronted with so W tank. Tnis conclusion is supported by much interference on 8280 kcs. from other the fact that no difficulty was experi- operators attempting to use the same fre- enced when the engines were switched to quency for other than distress purposes t he 1 r respective main tanks, and engines that he found it impossible to establish 1 and 2 continued to operate normally any satisfactory contact after gasoline had been transferred into Actually, Radio Officer Rea *s dis tress the left auxiliary tank and the engines call on 8280 kcse was heard by tne Coast were again operated from it. Guard, but they co^ld not reply before he Erratic operation of the quantity had changed bacl< to 8565 kcs. Investi- gauges for the right fuel tanks resulted gation disclosed, nowever, that one op- from the Insulation being burnt on the erator in a Coast Guard listening station, electric leads running from the tank because of lack of personnel, is at transmitters to the instruments, and the times required co guard as many as 9 wires being shorted. Engines 3 and 4 frequencies simultaneously, one* being failed not from lack of fuel, but because 8280 kcs Ir isy of course, virtually the leads from the master switch to the impossible for any one operator to listen primary coils of the magnetos were to and receive all calls on 9 frequencies grounded after the aluminum conduit and at one time, especially when considering insulation on the wires had been destroyed the noise and static which necessarily by fire,6 therefore, the changing of the accompanies reception on a frequency when fuel selector valves had no effect in re the volume is adjusted high. storing power to engines 3 and 4. No difficulty was experienced in es- tablishing communication on 8565 kcs. 6 See Appendix III These leads were found mounded All messages concerning the distress were at the time the airplane was examined The false fire warning from the No- 4 Board. However, as pointed out above, an engine resulted when the insulation on inspection of several C-54's disclosed in the electric lead had burned away, and a few cases that a chafed condition of the lead from the detector unit became the insulation on the "bus" bar existed energized by other wires and control in the vicinity of the engine control cables in the nacelle Since the fire pulley bracket The hazard of electrical warning detectors are located in zone 2 arcing and resulting fire was apparent of the nacelles, and the fire in nacelle The "bus" needed only to be pushed a 3, was in zone 3 in which there was no little closer to the pulley bracket, or fire detector unit, no indication of the allowed to vibrate a little longer so as fire m the No 3 nacelle was given until to wear more Insulation away before the the fire had progressed to the extent of same condition would have occurred as causing hot gasses to pass forward into that which confronted Captain Gregg in zone 2- By that time the conduit carry- this case. ing the magneto ground wire, had been de- Compliance with the intent of Section stroyed, and both engines had stopped 04 53 of the Civil Air Regulations which The discharge of the CO2 gas bottle in provides in part "...electrical systems zone 2 chilled the detector, and by nor- and equipment shall...be free from haz- mal action the fire warning light for en- ards in themselves.. .be installed in such gine No 3 went out a manner that they are suitably protected The No. 4 propeller could not be from., mechanical damage...," should h&ve feathered for the reason that the pro- prevented the type of bus bar installa- peller feathering motor electric lead was tion found in this particular aircraft. shorted as a result of the insulation Adequate clearance should have been pro- being burnt by the fire in nacelle No. 3. vided between the bus and the engine con- The loud noise heard by the crew was trol pulley bracket. Further, the bus the outboard tire on the right landing should have been securely anchored to the gear blowing out This tire had been aircraft structure so that chafing with burning m the nacelle, and the bungee adjacent parts of the aircraft would not cable had been so weakened by fire that have been possible. it broke when the gear extended. The ex- Had a fire warning device been avail- tension of the gear resulted from the up- able in zone 3 of the engine nacelles in gear latch, located at the top of the na- NC-88911, Captain Gregg might not have celle, being destroyed by fire Even had closed the shutoff valves into engine 4 the gear been retracted there would have which created the additional hazard of been no latch to hold it in position. engine 4 seizing from lack of lubrication Failure of the retracting mechanism was The* immediate warning of fire in zone 3, also a result of the fire in the No. 3 and the existence of an extinguishing nacelle. agent in that zone, should have enabled More confusing circumstances surround- the crew to put the fire out before it ing an emergency than those encountered had progressed to the extent of burring in this case would be difficult to im- the conduit carrying the magneto ground agine. There were several indications of wires which resulted in the stoppage of trouble In the fuel system, though no both engines 3 and 4. real trouble existed, there was no warn- Finally, this investigation disclosed ing of the fire m the No. 3 nacelle un- a need for a high frequency international til most of the wiring, plumbing, and distress channel Notice of the emergency engine control cables were destroyed, and in this case was possible largely because then there was the false warning of fire of the previously established radio con- in engine 4. The two right engines "out" tact on company frequency. Aircraft fly- right gear down combination resulted in ing without the benefit of company radio such an unsymmetrical flight condition would not have had this alternative that 125 miles per hour air speed was re- available. Little use can be made of quired to maintain directional control of search and rescue facilities if aircraft the airplane, and that air speed could be in distress at sea are unable to call for held only by losing altitude. help immediately after an emergency de- No other case of fire in the C-54 velops . It should also be noted that safety originating as this one did from arcing in overseas flights requires not only a between "bus" and engine control pulley satisfactory channel for communication bracket is known to the Civil Aeronautics of distress calls but also a dependable ---16824 listening watch of the channel. Only metal parts which resulted in power fail after these general requirements have ure of engines 3 and 4. been satisfied may the facilities of 7. No fire warning unit or extinguish- search and rescue be fully utilized. mg agent was installed in zone 3 of the engine nacelles in the aircraft Findings 8 The operator in a few of the Coast Upon due consideration of all avail- Guard listening stations is required to able evidence, the Board finds that guard as many as 9 frequencies at one time, one frequency being 8280 kcs. 1- The carrier, aircraft, and crew 9 Notification of the emergency was were properly certificated. transmitted on company frequency, 8565 2. No Irregularities were found in the kcs., and proper relay of the information maintenance of the aircraft, nor were any was sent through CAA Air Traffic Control, mechanical deficiencies found in any part to Coast Guard search and rescue of the aircraft, except as described be- 10. Search and rescue equipment was low. promptly dispatched, and intercepted the 3. A "bus" bar support was installed flight as it approached the eastern coast in the number 3 nacelle of NC-88911, made of the United States of fabricated dural not standard with the 11. The aircraft with the 2 right en- Douglas Aircraft Companys part, at a gines "out" was successfully crash-landed time and place not known. This support at Floyd Bennett Field. Fire and major held the "bus" closer to the face of the damage resulted to the aircraft, but no wing spar than the standard support found injury was sustained by the passengers in other C-54s or crew 4 Electrical arcing occurred between the "bus" and an engine control pulley Probable Cause bracket mounted on the face of the. front The Board determines that the probable wing spar and immediately below the "bus" cause of this accident was electrical In the No. 3 engine nacelle. A fire fed arcing between the battery "bus" and an by combustible fluids in the No. 3 na- engine control pulley bracket in the No 3 celle started from the electrical arcing. engine nacelle. This arcing resulted 5. The fire in the No. 3 nacelle burned from the lack of adequate protection for and destroyed the insulation and conduits the "bus." which protected much of the electrical wiring routed through the nacelle, in BY THE CIVIL AERONAUTICS BOARD particular, the magneto ground wires for I sf OSWALD RYAN engines 3 and 4. 6 The magneto ground wires, for en- /s/ HARLLEE BRANCH gines 3 and 4, became grounded on adjacent / s/ JOSH LEE --- 18824 I Engine 2 Engine 3 Engine 4 Engine Carburetor Carburetor Carburetor Carburetor Engine Driven Pump Engine Driven Pump Engine Driven Pump Engine Driven Pump Fire wall Firewall Fire wall Firewall Emerg Firewall Emerg Firewall Emerg Firewall Shutoff Valve Shutoff Valve Shutoff Valve Strainer Strainer L Aux Tank Selector R Aux. Tank Select Strainer S trainer Valve (3 Post ion) Valve (3 Position) Appendix Cross feed Crossfe^d Crossfeed Cross feed Valve k Valve Valve Vai ve Tank Select Tank Select Tank Select Tank Select Valve Valve Valve Valve * nm Tank Drain Tank Drain Tank Drain Tank Drain Tank Dram Tank Dram 1 / Mam Tank Left Auk Tank 2 Mam Tank 3 Mam Tank Right Aux Tank 4 Mam Tank Cap 495 Gal Cap 4 31 Gal Cap 508 Gal Cap 508 Gal Cap 4 31 Gal Cap 4 95 Gal * FIG 2 FUEL SYSTEM DIAGRAM- SCHEMATIC C54B-DC 4 TANK SYSTEM PREPARED BY PAA Obtained from RareAviation.com. See our selection. Copyright (c) 2004 ---"v !4 Inches 9 Inches To Middle To Inboard Bracket Support fn/ima f^nrttrn! r.nhl^c VM3B < Main Bus Appendix I " - J 8 FRONT VIEW 00 Obtained from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviation.com Apps^dh The damage which occurred in the No. female receptacle insulation and male 3 nacelles Zone 3? has been divided into pins the following areas 7. Lugs and wiring associated with re- verse current relay in firewall junction 1. The region immediately behind the box snow discoloration. Wire from equal- firewall. izing resistoi to ground shows scorched 2. The sides and top of the nacelle insulation. egicn. 8. Feathering motor power wiring in- 3. The front face of the spar region side the firewall junction box showed 4. The under wing wheel well fairing evidence of heavy currents at the sole- region. noid . The material which follows has been further subdivided into the following Sides and Top of Nace He Reg son sections Fluid Systems and Plumbing (a) Damage wbicn occurred to the 1. Carburetor vapor "eturn line burned fluid system and plumbing. in half at a point 36" aft of firewall (b) Damage to the structure< (outboard rear side of nacelle) for a (c) Damage to the electrical system distance of 12. Then at a point 2" aft and electrical components. of the break it is deformed by heat for a distance of 3 1/2 pressing on aft out- Region Behind Firetail board nacelle gusset. Fluid Systems and Plumbing 2. Rubber in gang line clamps blis- 1. Oil out line hose connection tered, 12" from spar, outboard rear side burned on aft side. Not leaking. of nacelle. 2. Feathering supply line hose con- 3. Carburetor alcohol supply line bro- nection charred at oil tank on aft side ken 10" from tee between No. 3 and No. 4 only. Not leaking. solenoids, outboard rear side of nacelle. 3. Line lashings burned off at R.H* A 5" section is burned out from this side of firewall. point as it passes over to face of spar. Structure 4. propeller alcohol line has 3 sec- 1. Inboard oil tank strap broken with tion burned out starting 1 1/2" from un- strap pad burned out. Outboard strap ion in line. This is in same location as carburetor alcohol line in the previous pad burned and blistered. ite 2. Upper landing gear door fitting IF bent upward (probably in landing) . 5. Three deicer air pressure lines 3. Landing gear door mechanism spring burned across top of nacelle over tires - stretched permanently and overheated. Severe burning from entrance at nacelle (Due loss of spring tension when heated.) side walls to area ozer top of tires. Electrical Inboard of nacelle centerline burning 1. Upper inboard fire warning wiring starts 12" inooard of nacelle centerline insulation burned off to where it touches and lines completely burned from 18 from oil tank overflow line and 3" each way centerline to inboard slue of nacelle from this point as it branches out. Wire (10") e Outboard of nacelle two lines insulation charred about 12" beyond bare burned off at side of nacelle completely wire. for 9" and one from side of nacelle up to 2. Wiring from oil pressure and fuel top of nacelle to hose joinL. pressure warning switches on firewall 6. Capped oil transfer line for ^To0 3 blistered and charred to nacelle junc- engine (not in use, but containing engine tion box. oil blocked off) burned or oroken top ena 3. Generator field and volf-ammeter off including cap and sws heavy slack circuit breakers on nacelle junction box carbon deposit on line from upper end as had not opened. overflowing oil flowed out without pres- 4. Wire bundle right side of firewall sure. This line is in inboard rear cor- blistered to firewall junction box. ner of nacelle Oil still in open end of 5. Upper outboard fire detector wir- line. ing insulation burned off from Adel clamp 7. Oil transfer line for No. 4 engine to wire bundle (6") . following same routing as deicer air 6. Magneto plug and receptacle on pressure lines has 9 section burned out firewall showed moderate blackening of over outboard tire This was an unused 1Q(^tained from RareAviation.com. See our selection. Copyright (c) line and little if any oil was released nacelle burned and charred 2/3 back fro: II from it. No oil in line. firewall. From this point to terminal Structure strip at spar, wire was bare Wire loose I. Nacelle longitudinal just outboard from terminal strip which is oumed out. of top centerline of nacelle burned out 2. Wiring along right aft side of na- from 37" to 41" aft of firewall. Same celle up to carburetor deicing solenoids area as burned out deicer lines. was raw and burned through 16" from sole- 2- Rearroost nacelle frame (transverse no ids ring) burned away for 10" over outboard 3. The flexible lead from the main bus tire. Cracked at top at nacelle center- to the firewall junction box had insula- line and 10" outboard of centerline. tion burned off 33 1/2" forward toward Mashed forward 13" outboard of center- the firewall. Copper appeared subject to line (by heat) . high overheat condition but not enough to 3. 6" section of nacelle frame burned melt. Clamps for this lead burned leav- out in area of burned out deicer lines ing lead hanging loosely in nacelle. over inboard tire. 4. Wire bundle inboard side of nacelle 4. Upper Inboard pulley bracket charred. mounted to top rear of nacelle entirely burned out except for stubs attaching to Front Face of Spar Region nacelle hat sections. Stub ends of Fluid Systems and Plumbing bracket casting show one melted stub and 1. Manifold pressure line (1/4" tub- four broken stubs. Bracket Is magnesium. ing) broken In two at a point 8" from 5e Upper outboard pulley bracket outboard sidd of nacelle. mounted to top rear of nacelle entirely 2. Vacuum line hose from No. 4 nacelle burned away except for stubs attaching to blistered on forward side, outboard side nacelle hat sections. Stub ends of of nacelle. bracket casting show six melted and one 3. No Adel clamp rubber burned below broken stubs. Bracket is magnesium. 12" above bottom spar cap. 6. Hat section top rear of nacelle for 4. Note Carb, vapor return line, attachment of outboard pulley bracket carb, alcohol and prop, alcohol lines broken. Also four other hat sections at burned through in outboard rear corner of top of nacelle same area were broken. wheel well were listed under the "Sides These also show severe burning, proba- and Top of Nacelle Region" could also be bly weakened sections cracked in landing. listed in this section as they are close 7. Molten metal from pulley brackets to face of spar also. found lying on lower spar cap, on aft end Structure of landing gear doors (proving they were 1. No. 3 engine R.p M.. carb, air closed during magnesium fire) and on re- temp, throttle, mixture and supercharger, tracting strut cylinder lower end. Lo- two each control cables (3/32 steel) cations are---on spar rail, 12" from in- burned through at pulley bracket. board side of nacelle. On doors both 2. No. 4 dump valve cable burned sides, 16" from centerline of nacelle. through at pulley bracket. 8* Nacelle skin area which was over 3. Three cables (2 mixture and 1 short burned inboard deicer air pressure lines piece unattached 6 1/2" long) welded to- had soot smudged as if by some contact --- gether at point where they burned possibly piece of tire. through. 9. Nacelle hat section stringer 26* 4. Two cables (supercharger) xvelded aft of firewall and 22" Inboard of na- together at burned end. celle centerline is dented locally. 5. Wire bundle (40 wires) sagging down 10. Top inboard nacelle longitudinal 18" due to support brackets burned off. at a point 33" aft of firewall was dented 6. All mlcarta pulleys in pulley toward center of nacelle. brackets on face of spar burned out leav- II. Landing gear uplatch had one link ing only center bearings. Exception 2 broken and shear pin sheared downward pulleys only half burned-*-located most about one-half way through. aft, next to spar web. 12> Cable fair leads at top of na- 7- Bus support brackets. Outboard celle burned out. bracket bent up and burned away par- Electrical tially. Center bracket burned away to 1. Oil quantity gauge wiring from top 4 1/4" of spar. Inboard bracket burned of oil tank along top inboard side of off to 4 1/8" of spar. Diagonal leg -* 188 24 support for this bracket hanging loose 7. Little pieces of engine control and burned off to 4 5/8" of spar cable wire welded to bus where cables 8. Outboard spar face pulley bracket laid on the bus after burning tn two. had all pulleys burned out, but bracket One piece outboard of break and three in- was not melted. board of breax. 9. Main spar face pulley bracket 8 Termjnal strip at inboard aft end (nearest bus) nad upper forward section of nacelle close to upper magnesium pul- burned away directly below bus separa- ley bracket which burned had disappeared tion. All pulleys, except as noted in in fire and wires attaching to it were item 6 burned out leaving pulley bearings burned and hanging loose. on bolts which still remained. 10. Uplatch cable bellcrank located Under Wing Wheel Well Fairing Region about 8" aft of spar on top wing surface Fluid System and Plumbing was pulled out of its support bracket 1. No. 3 main tank outlet hose at which was partially burned #way booster pump blistered and found leaking 11 Top wing skin aft of spar warped a small amount a day after the accident. from heat 2. Fuel line from strainer to bottom Electrical wing skin fitting (thence leading to in- 1. No. 4 engine wire bundle mounted board side of nacelle and forward to No. just forward of bus had insulation burned 3 engine firewall shutoff valve) had off all but two wires (38 wires) for 56" piece about 3/4 x 1 1/2" broken, out. At across back of wheel well and extendin ?4 upper end of line below wing skin fit beyond side of nacelle 6" on outboard side (this was not protected by nacelle ting, line was severely burned and cracked, but no part of the tube was sidewall) . Wire bundle blistered 5 be- missing. yond burning on inboard side and 7" be- 3. Dural drain line from No. 3 main yond on outboard side. tank drain valve burned off from exit 2. In same wire bundle, 18 out of the grommet in fairing back 16" toward valve 40 wires were burned until broken, and 2 Hose attachment burned through on bottoi re wires (thermocouple head temperature side. gauge) which had asbestos covering still 4. Air brake line burned off at bottom had asbestos covering although it was be- wing skin fitting. ginning to fall off and was not insulat- Structure ing wire in region near pulley bracket. 1. Fairing frame 14" aft broken fuel 3. 45" of No. 4 engine magneto ground line was severely burned with top edge of wire conduit which ran across nacelle dural sheet burned away. near main bus was burned out, wire insu- 2. Bottom wing skin warped and cracked lation burned off and wires broken. One in one place. Most intense on outboard wire burned in half 42" from outboard side side of nacelle (4" from inboard side) Electrical and the other wire 7" from outboard side 1. Wire bundle from inboard side of of nacelle (41" from inboard side) . nacelle down and hack to Junction box on 4. Main bus (from No. 3 and 4 engines) outboard side of under wing fairing re- burned through 15" from inboard wall of gion had raw wires from Junction to rear nacelle (from bottom edge of main gusset) side of landing gear retract strut (out- and 32 5/8" from outboard wall of nacelle board side of region) , semi-raw for 'an- (from bottom edge of main gusset) . In- other 6" and charred from there to the sulation burned off of bus from Adel forward edge of the nacelle fairing, clamp at outboard gusset for 51" across gradually tapering off to O.K. at en- face of spar . Bus completely bare for trance into wing at inboard side of na- 47" of this distance. celle. 5. Extra white condition of burnedbus 2. Wire bundle from under wing Junc- 7" outboard to 3" inboard of bus separa- tion box aft to rear main strut attach tion. (Due te magnesium pulley bracket fitting (region aft of broken fuel line) fire.) bare. 6. Inboard segment of bus touched up- 3. Wire from bundle in item 2 which per corner of pulley bracket. This cor- led to landing gear strut extension ner had about 1/4" burned off. Dimension safety switch was blistered in nacelle region. of bus to spar is 4 7/8" as found, both 4. Inside of Junction box all wiring segments. was burned, some bare, but terminal strip had not disintegrated Junction box spar (near region of broken fuel line) front cover blackened smoothly on inside burned, particularly on outboard side but only spotted from burned rubber nearest broken fuel line. (tires) on outside. 7. Wires to No* 3 main boost pump, 5. Heater solenoid near front of fair- outboard side of this region, burned off ing, on outboard side overheated and at pump connection. This connection was wire bare from solenoid to Junction box. well cooked inside. 6. Landing gear up microswitch at cen- ter of nacelle mounted under wing aft of ---18824 SA-[55 File Ho. I 099-47 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted! March 21, 1949 Released March 21, 1949 PAN AMERICAN A 1 RWAYS---ANNETTE ISLAND, ALASKA---OCTOBER 26, 1947 The Accident Island at 1338 after a routine trip. At approximately 1345, * 1 October 26, Earlier, at 1326, the company radio at 1947, Pan American Airways1 Flight 923, a Annette Island had transmitted a weather DC-4, aircraft NC 8 8 9 20, crashed on the observation which reported an indefinite north side of Tamgas Mountain, Annette 1,400-foot ceiling, overcast, lower bro- Island, Alaska. The 13 passengers and ken clouds, visibility of 3 miles, ram, ere* of 5 were killed, and the aircraft wind southeast at 28 miles per hour, was destroyed. with gusts to 40 miles per hour. The flight acknowledged receipt of this in- History of the Fl ight formation Flight 923 departed at 1030 October Airway Traffic Control cleared the flight to pass over the radio range sta- 26, 1947, from Seattle, Washington, for tion located 1 5 mile northwest of the Juneau, Alaska, with an intermediate stop airport at 7,000 feet and then to pro- scheduled at Annette Island Captain Alf ceed with a normal instrument letdown X Monsen flew as pilot ana First Officer and approach to the field The flight Laurence A Foster as copilot. The air- acknowledged this clearance, and re- plane carried 13 passengers including an ported its position over the radio range infant, a crew of five, 2,500 gallons of station at 7,000 feet at 1338 The nor- fuel, and 822 pounds of cargo. This load mal instrument procedure for Annette Is- was within the allowable airplane weight land was established with regard to the and was properly distributed m respect mountainous terrain east and northeast to the center of gravity of the airport, which rises to an eleva- Company weather information given to tion of 3,596 feet on Tamgas Mountain. Captain Monsen before departure was to This procedure required the flight, aft- the effect that there would be unlimited er approaching from the south at 7,000 ceiling from Seattle to Comox, British feet and reporting over the radio sta- Columbia Then at the cruising altitude tion, to remain west of the south course of 9,000 feet, instrument conditions, of the range while on instruments 2 light icing, and light to moderate turbu- Five minutes after the flight re- lence was expected over the route. Winds ported over the range station, at 1343 were forecasted to be from 200 to 230 de- it advised Annette Radio that it was grees at 30 to 40 knots. It was also proceeding to Juneau, approximately 250 forecasted that at the time of the miles north-northwest of Annette Island, flights arrival over Annette there would because of extreme turbulence This was fee an 800-foot overcast, lower broken the first indication that the flight was clouds, 4visibility of 2 miles, light encountering any difficulty in accom- ram, and a surface wind from the south- plishing a normal letdown and approach Southeast at 18 knots A cold type oc- to the airport. In response, Annette clusionor front which was moving toward Radio asked the flight to report its al- Annette Island from a point about 375 titude, but there was no reply. After miles west of there was expected to pass repeated calls to the flight Annette Ra- Annette Island before the flight arrived. dio issued an alert at 1401 It was es- Proceeding en route in accordance with timated that the flight at the time of an instrument clearance to flv at 9,000 its last radio contact had aboard 9 feet, the flight arrived over Annette hours and 16 minutes of fuel. All tines noted herein are Pacific Standard and 4 See Appendix 1 based on the 24-hour clock ---16S77 (1) Obtained from RareAviation.com. See our selection. Copyright (c) 2004 At approximately 1430 the Civil Aero- A few parts of the 12 propeller nautics Board was notified, and a search blades were not recovered, but all the by air, land, and sea was immediately be- propeller hubs and domes were located. gun. However, adverse weather conditions The shearing of the engine nose sec- retarded the search to such a degree that tions, and the degree of propeller the wreckage was not located until 5 days breakage indicated that none of the pro- after the accident October 31, 1947. It pellers were feathered. One engine was was found that the airplane had crashed badly shattered. The remaining 3 en- on the north slope of Tamgas Mountain, gines were found relatively intact. approximately 8 miles east of Annette Is- A flash fire occurred at the time of land Airport and 8 miles east of the impact, but there was no evidence of a south course of the Annette radio range fire in flight. The Fluxgate Compass was found with Investigation the needle jammed at 116 degrees, and The aircraft struck the north side of adding the 29 degrees which would have the mountain at an elevation of approxi- been subtracted for easterly deviation, mately 3,400 feet , 196 feet below the results m a true course of 145 degrees, summit Rescue parties ascending the or the same as estimated from the ground mountain were hampered by rain snow, and markings Excepting the Fluxgate Com- fog The wreckage, scattered over 20,000 pass, all flight instruments were bat- square feet, was buried in snow, and 5 to tered beyond readability, In like man- 6 inches of snow fell while the bodies ner the flaps and landing gear, and were being removed. Consequently, a de- their actuating mechanism were damaged tailed examination of the wreckage was too extensively to determine positions, impossible until after the summer thaw The slopes of Tamgas Mountain and the melted the snow. surrounding area, much of which was cov- In late August, 1948, the time of max- ered with forest, were observed from the imum thaw on Tamgas Mountain, another air in a search for parts which might party reached the wreckage and made a have fallen in ^flight None were found, thorough examination. Airplane parts nor were any marks in the ground or were scattered on extremely rugged ter- abrasions on the trees discovered which rain, and were exposed for examination would have indicated contact by the air- except for the right wing, the major por- craft prior to the accident tion of which was m a crevice beneath a All of the maintenance records of NC deep crust of ice 88920 from the time of its acquisition About 50 feet above the location of by the company were carefully examined, the wreckage on a projecting wall of rock and the operating history of the air- there were 4 marks made by the No. 4 pro- craft since its date of manufacture was peller These marks, which were equally studied. From all the records it ap- spaced, showed that the aircraft had peared that the aircraft had been prop- struck the wall of rock at an angle of erly maintained, and was airworthy at about 45 degrees to it, and in a 20 de- the time of its departure from Seattle. gree climbing attitude, From these mark Captain Monsen, age 47, held an air- mgs and the markings left by the nose of line transport pilot rating and had the fuselage it was estimated that the logged a total of 13,565 hours, 514 of true course of the airplane had been which were in DC^l type airplanes He about 145 degrees at the time of impact. had been employed as a pilot m Alaska Since the actual propeller-pitch setting since 1928, and employed by Pan American could not be determined, or the rpm set- Airways since 1932. In 1941, prepara- ting known, the distance between propel- tory to the opening of a Pan American ler blade marks was not reliable in com- Airways route between Seattle and Alas- puting the air speed of the aircraft at ka, Captain Monsen was sent to Browns- the time of impact * ville, Texas, for training, After 66 hours in DC-3 airplanes and 44 hours in Stinson airplanes, 38 hours of which was S Coast and Geodetic Survey charts, reissued instrument time, he received an airline May 19, 1938, and the Aeronautical charts available to transport pilot rating. He was then the crew or Flight 923, showed the elevation of Tamgas Mountain to be $610 feet A recoputation sent on a flight of 66 hours to Trini- of the elevation subsequent to the accident showed It dad, British $est Indies, m a DC-3 air to be $ 596 feet, or 14 feet lower than the published elevation plane, following which he returned to Seattle and was one of the pilots who being over the station, testified that opened the new route# Thereafter, he the operation of the radio range was sub- continued to fly for the company until stantially normal. The range is contmu- the accident Out of the 7 2 hours pre- ously monitored by the Petersburg, A1 as- ceding the accident, Captain Monsen had ka, CAA Communications Station, and its flown 9 hours and 11 minutes, and had had records indicate that the signal re- a rest period of 48 hours immediately ceived, signal strength, and We func- preceding his departure from Seattle. tioning of the Annette Island Range was His last CAA physical examination was normal. taken October 2, 1947. His last instru- An aftercast of weather over the route ment flight check was taken March 10, of Flight 923 showed that tne forecast 1947, and his last route check over the was substantially correct except for the route of the accident was taken April 10, high winds and turbulence which existed 1947 over Annette. The departure from Seattle First Officer Foster, age 39, held ar was made under conditions of unlimited airline transport pilot rating and had ceiling and good visibility, with a light logged a total of 12,412 flying hours, of surface wind from the northeast. When which 359 had been tn DC-4 type air- the flight had climbed to cruising alti- planes. After over 8 years of experience tude, 9,000 feet, the wind became south- as a captain for United Air Lines, he had westerly at 15 to 20 miles per hour. been hired as a captain by Pan American Upon arriving over Comox, British Colum- Airways. However, because of a temporary bia, the flight encountered, scattered to reduction m personnel, at the time of broken high ana low clouds, which in- the accident Mr Foster was serving as a creased to occasionally-broken overcast senior first officer, His last CAA phy- as the flight progressed Southwest slcal examination was taken October 10, winds at 30 to 35 miles per hour were en- 1947, and his last instrument check was countered upon the flight1 s arrival over taken August 15, 1947 Mr# Foster had Port Haraj^ . From there until it reached had a 48-hour rest period immediately Annette Island, the flight was either m preceding his departure from Seattle. clouds or between cloud layers, with var- Both pilots had completed a familiari- iable icing and'light to moderate turbu- zation course m DC-4 airplanes in March lence Winds progressively increased in 1947, at the time these aircraft were put velocity to 50-60 miles per hour. De- into operation by Pan American Airways. scending to Annette Island Airport, the Although Captain Monsen was expected to flight experienced a veering of the winds complete one hour a month, and First Of- to the south at 5^000 feet, and to the ficer Foster 2 hours a month in link southeast near the ground Below 5,000 trainer instruction, no records were feet the passage of strong winds over the available to show whether this training mountainous terrain produced a marked in- was accomplished. crease m turbulence. Particularly was C L. Dunwoody, the flight engineer, this true over and to the leeward of the age 28, held a flight engineer certifi- mountains, where strong to locally-severe cate and had flown approximately 2,292 turbulence and downdrafts on the northern hours. His last CAA physical examination slopes were likely. was taken June 20, 1947, and he had had a The flight was conducted within a bar- 48-hour rest period immediately preceding ometric pressure field of a very regular his departure from Seattle. pattern, without fronts or marked squall A flight check of the Annette Island lines. Consequently, any sudden changes Radio Range on October 28, and *29, as in wind velocity or direction above 7,000 soon after the accident as the weather feet between Seattle and Annette Island permitted, showed that the northwest would have been very unlikely. At low course was in error 3 1/2 degrees clock- altitudes, as stated, the terrain would wise, or towards the northeast.4 Errors disturb the flow of winds both as to di- of 1 1/2 degrees or less are considered rection and velocity. within tolerance. A United States Air Upon the flights arrival in the An- Force pilot, who landed at Annette Island nette Island vicinity, there was trans- '23 minutes before Flight 923 reported mitted at 1256 a special surface weather observation, which was Ceiling indefi- 4 This displacement was adjusted and the northwest nite, 1800 overcast, lower broken, visi- course was found within tolerance on a re-check October 29th bility 4 miles, moderate rain, wind east southeast 28, strong gusts, altimeter still approximately 100 miles west of 29.57, overcast estimated at 2600 Annette Island. The original forecast The Army pilot who landed at Annette was in error also m respect to the wind Island 23 minutes before the arrival of velocities. It should have been evident Flight 923 described the weather condi- to the company meteorologist that the tions en route from Tacoma, Washington to synoptic situation existing over the Annette. In letting down preparatory to northeast Pacific would result in crowd- landing at Annette Island, the pilot tes- ed isobars along the Canadian and south- tified that he encountered slight turbu- east Alaska coast. Had this been real- lence at 6,000 f^et, which grew progres- ized, he would have forecasted much more sively more severe down to about 400 severe turbulence at low altitudes m feet. Prior to descending, he had en- ample time for the information to have countered intermittent light rime ice at been available to the pilot either be- 7,000 feet, and during the descent light fore or shortly after his departure from to moderate ram. Seattle Approximately 3 hours after the last transmission of Flight 923, a non- Analysis scheduled air carrier aircraft landed at Since no evidence was found which Annette Island from Whitehorse, Y, T., would maleate structural or mechanical Canada. Moderate ice was encountered be- failure, and since the maintenance and tween 9,000 and 7, 000 feet in the vicini- historical records of the aircraft ty of Annette Island, and upon descending showed no discrepancies, there is no ba- to 6,000 feet turbulence was experienced sis for attributing the cause of this which grew progressively severe as the accident to a mechanical failure in the aircraft descended. The pilot of this airplane or any of its components. flight stated that the turbulence had Displacement of the northwest course been so severe on several occasions to al- of the Annette Island Radio Range cannot most tumble the gyro flight instruments. be considered contributory to the acci- Six hours after the Army flight accom- dent- Even if deflected 3 1/2 degrees plished a normal landing at Annette Is- east, the northwest course of the range land, the pilot took off again. Immedi- would not at the closest point be less ately after leaving the ground he encoun- than 10 miles from the mountains north- tered extreme turbulence which decreased east of the radio range station. It is in severity until he reached smooth air evident, therefore, that had the flight at about 6,000 feet. Between 4,500 and followed this course, it could not have 6,000 feet severe icing was encountered. flown into Tamgas Mountain. Further- At 8,000 feet altitude could no longer be more, the Army Air Force pilot who used maintained because of ice though full the range and landed at Annette 23 min- power was applied, so a return to Annette utes before Flight 9'23 arrived, reported Island was necessary the operation of the range to be sub- Prior to the departure of Flight 9 23 stantially normal 5 from Seattle, the company meteorologist Underestimation of wjnd velocities at forecasted that the occluded front moving the time of flight planning resulted in shoreward toward Annette Island would the flights arrival at Annette before pass there before the flight's arrival. the time originally calculated. But This forecast was not in accordance with this does not appear m itself to be the forecasts of the. United States and significant. Apart from turbulence, the Canadian Weather Bureaus. At 1229, when effect, if any, of stronger than ex- the flight was approaching Annette Is- pected winds, in view of their easterly land, the company meteorologist dis- component in the vicinity of Annette, patched a revised forecast "Expect oc would have been to drift the airplane elusion reach Annette Island and Juneau away from the accident area rather than 0000Z (1600 Pacific Standard time) . On toward it However, turbulence was the arrival Annette Island terminal 1000 product of the high soutneasterly winds overcast, visibility 3, light rain, SE in the vicinity of Annette Island. A 25, gusts to 50....." Since no record of more accurate forecast of these winds and a transmission acknowledging receipt of the resultant turbulence may have served this revised forecast was found, it prob- ably did not reach Flight 923 Actually, at the time of the accident the front was 5 See Appendix 1 to warn the ce^ of Flight 923 of the 4 Routine position ^no^ts ^ere re- very condition which they reported in ceived from me flight until 1338 when it their last transmission reported being ove" tre Annette island There are several possible explana- Radio Range Station at 7,000 feet tions for this accident Severe turbu- 5 The flight reported to tn e Annette lence may nave caused a loss of control Island Radio at 1343 that it ras aban- of the airplane There nay have been se- doning its approach due to extreme turbu- vere icing which resulted in a loss of lence, and that it would -proceed to Ju- control There are other possible theo- neau. ho further co^muni^at*on was re- ries , but it remains impossible to ex- ceived f-om t^e flight plain why the flight was unable to stay 5 TI e ai~c~aft 1 as o" a true on the proper side of the radio range, of 145 degrees and a 20 degree climb- and why it was flying a neadmg of 145 ing attitude at time of impact. degrees Outside of the fact that severe 7 The flight c^asned on tre "o^th turbulence and icing conditions existed side of rtc Tam gas at a point eigne riles over Annette through wmrh tre flight hao. east of tie Annette Island airport, to descend, there is no 1 eal evidence to eight ^"les east of tve south course of support any particular theory for the the Annette ~ad^o range, arc at an ele- cause of this accident Therefore, the ---w--- nation oi 3,400 feet probable cause of ch^j accident remains 8 bo evidence vas fou^d of engine undetermined malfunctioning or structural failure p^io^ to the time of the crash 9 Annette Island Range was function- On the basis of all the available evi- ing normally at the time of tre accident dence the Board finds that except for a displacement of 3 1/2 de- 1 The aircraft, crew, and carrier grees east of tne northwest course were properly certificated 2, The aircraft maintenance and his- Probabie Cause torical records indicated that the air- plane had been properly maintained and was airworthy at the time of takeoff for The Boara fi^as that tre^e is not sufficient evidence to determine the the flight from Seattle at 1030, October probable cause of thxs accident 26, 1947 3 The company forecast did not in- BY TIE CIVIL AERONAUTICS 32 3RP clude information concerning the exces- /s/ JOSEPH J 0ir'Gf . J? sive turbulence which the flight experi- enced over Annette Island, though exces- Is! OSb&LD sive turbulence could reasonably have /si JOSH ZEE been forecasted from available weather /s/ HAROLD A JOI/ES data. Is/ RUSSFLL S A^S --- 16577 Supplemental Data Investigation and Hearing last check over the route involved, April 10, 1947 His last CAA physical examina- The Civil Aeronautics Board was noti- tion was on October 2, 1947 First Offi- fied at 1430, October 26, 1947. An in- cer L A. Foster, age 39, possessed a vestigation was begun immediately in ac- valid airline transport pilot rating and cordance with the provisions of Section had logged a total of 12,412 flying 702 (a) (2) of the Civil Aeronautics Act hours, of which 359 were in DC-4 type of 1338, as amended. A public hearing airplanes. His last instrument check was was ordered by the Board and held in Se- taken August 15, 1947. His last CAA attle, Washington, December 3, 19 47, and physical examination was on October 10, September 29, 1948 1947. The flight engineer, Curtis L , JLJ. Dun --- Air Carrier woody, age 28 , held flight engineer cer- Pan American Airways, Inc., a New York tificate 575026 His last CAA physical corporation with headquarters m New York examination was passed June 19 1947. City, is a holder of a certificate of The other two members of the crew were public convenience and necessity issued the check purser, Mary E. Chidiac, and by the Civil Aeronautics Board and an air the purser, Helen H. Darrah. carrier operating certificate issued by the Civil Aeronautics Administration The Aircraft NC 889 20, a Douglas DC-4A aircraft, had been flown a total of approximately 4,146 hours. Captain A. N. Monsen, age 47, pos- The No. 1 engine had a total of 1, 157 sessed a valid airline transport pilot rating and had logged a total of 13,565 hours, the No. 2 of 1,181 hours, the No flying hours, of wmch 514 were in DC-4 3 of 1, 170 hours, and the No 4 of 1, 218 typ e ai rpl an es . His last instrument hours All had had 232 hours since check was taken March 10, 1947, and his overhaul. --- 16377 (I) II Accident Investigation Report --- 16577 SA- 258 1-0026 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: September 233 1952 Released: September 26, 1952 PAN AMERICAN WORLD AIRWAYS, INC. - SAN JUAN, PUERTO RICO, APRIL 11, 1952 The Accident A Pan American World Airways aircraft, a Douglas DC~U, N 88899, was ditched at approximately 1220,1' April 11, 1952, about eleven miles north- west of San Juan, Puerto Rico, after taking off from the Isle Grande Airport. On board were five crew members and 6U passengers, including six infants. Fifty-two passengers Lost their lives as a result of this ditching, and the aircraft sank m water approximately 2,000 feet deep and could not be recovered History of the Flight Pan American Iworld Airways1 Flight 526A originated at San Juan and departed there at 1211, April 11, 1952, for New York, New York. The crew consisted of Captain J. C. Burn, First Officer W. T. Hutchins, Second Officer J. R. Laubach, Purser A. Perez, and Steward R. Torres. According to company records, the air- craft at the time of takeoff weighed 31,868 kilograms (70,256 pounds), which was within the allowable gross takeoff weight of 33,113 kilograms (73,000 pounds). The load was properly distributed with respect to the approved center of gravity limits of the aircraft. Prior to departure, the captain filed with Air Route Traffic Control an IFR (Instrument Flight Rules) flight plan to New York International Airport, New York, to cruise at an altitude of 8,000 feet, estimating the flight tune as eight hours and three minutes. This flight plan was approved. The crew testified that the aircraft was taxied to the end of Runway No. 9, the pre-takeoff check made, and the takeoff run started. During the takeoff and the initial climb, the aircraft appeared to be sluggish but not to an extent to cause concern. At an altitude of approximately 250 feet with the gear up, the flaps were raised and power was reduced to climb power. Climbing at an indicated air speed of 155 miles per hour, the first officer noticed that the oil pressure of No. 3 engine was falling and the oil tempera^ ture increasing. This condition was immediately pointed out to the captain 3 who requested that the San Juan tower be advised that they were returning to the airport. Accordingly, at 1213 the flight advised the tower of its in- tentions, and the tower replied, Roger 526A, cleared to Land, Runway 9, wind 1/ All times referred to herein are Atlantic Standard and based on the 24 hour clogk. from RareAviation.com. See our selection. Copyright (c) 2004 From PilotManuals.com / RareAviaTion.com r 3 a ' ** 2 east one eight, altimeter two nine nine five. I'll notify your company." The company was notified and upon request, emergency field equipment was alerted. Because the oil pressure of No. 3 engine continued to drop rapidly and the oil temperature correspondingly increased, the propeller of this engine was feathered and power was increased to rated power on the remaining three engines. By this time the aircraft's altitude was approximately 350 feet. When power was increased, the No. U engine oackfired several times; however, immediately following tnese backfires, the engine continued to run in a normal manner. A climbing turn was initiated to a westerly heading, and the captain said that for best climbing conditions he reduced the aircraft's air speed during the turn to 145 miles per hour. This reduction in air speed was accomplished by using up elevator. Upon reaching an altitude of about 550 feet, No, 4 engine again bacxfired and ran rough. Manifold pressure was reduced on this engine to approximately 32-35 inches, and again the engine ran smoothly. Subsequent attempts to operate No. 4 engine at increased power were unsuccessful due to recurrent roughness At 1217 the tower asked the flight to report its position and received this reply: "We are still quite a way out.1 And at 1218, the tower advised the U. S. Coast Guard Rescue Coordination Center at San Juan that the flight was in trouble and gave its position as seven miles, 300 degrees from the tower. The captain gradually reduced the air speed to 135 miles per hour, and at this time the heading of the aircraft was changed slightly to the right to maintain a course approximately parallel to the coast line. Because the air- craft was losing altitude, engines No. 1 and No. 2 were increased to takeoff power. The second officer was sent to the passenger compartment to advise the purser and steward that fuel was to be dumped, and all fuel dump valves were then opened. After the second officer returned to the cockpit, the flight advised the tower, at 1219, that it might have to ditch, and the captain in- structed the second officer to alert the passengers. The second officer re- turned to the cabin, indicated that a ditching was imminent, took a f orward seat m the cabin and fastened his safety belt. At 1220, an Air Force fr-47 flying in the vicinity notified the San Juan tower that a DC-4 seemed to be ditching and accordingly was advised to circle the area. Flight 526a continued to settle, and the throttles of engines Nos. 1 and 2 were advanced to their stops With the air speed near 120 miles per hour, the flaps were lowered to five degrees . Shortly after this, a landing on the water was made. The landing gear and flaps were lowered, and the fuel dump valves closed. The second officer obtained a life raft, which he carried to the main cabin and launched through a forward emergency exit on the right side. The first officer, after an unsuccessful attempt to loosen another life raft, abandoned the aircraft through a cockpit window. The captain entered the cabin and assisted passengers in evacuating the aircraft through the mam cabin door until he was swept overboard by the action of the sea against the door. The aircraft sank approximately three minutes after landing on the water. W At the time of the accident the weather was: high broken clouds at 35,000 feet with lower scattered clouds at 3,000 feet, visibility 20 miles and wind from east-southeast, 16 miles per hour. Investigation From a large oil slick which was observed on the water following the sinking of the aircraft, it was determined that the ditching occurred at latitude 18 32.6' north and longitude 66 15.5 west. This is approximately four and one-half miles off the north coast of Puerto Rico and eleven miles from the airport. Captain Burn said that when the "pre-takeoff" check was accomplished all engines operated normally but that during the takeoff the aircraft was a little slow in accelerating. However, the engine instruments indicated that they were delivering normal power with all pressure, temperature, and fuel flow gauges indicating a normal operation. According to the captain's testimony, from the time No. 3 propeller was feathered until landing on the water, he was either attempting to establish a climb or was flying the aircraft in a nose-high attitude m an effort to maintain altitude, and air speed and altitude were diminishing throughout the entire period. He stated that because the aircraft was con- tinuing to lose altitude, he changed his original heading, which was toward the airport, to avoid a possible forced landing m a congested ara or on a coral reef. He stated that no appreciable yawing of the aircraft was noticed when the No. 3 propeller was feathered, and that after a minor trim correction he experienced no difficulty m maintaining directional control Throughout the latter portion of the flight, the first officer had the check list in hand, and both he and the captain checked all the instruments and controls m the cockpit seeking an answer to the aircraft's continuing loss of air speed ana altitude. This check also showed all controls positioned properly and engine instruments indicating normal operation for the conditions involved. The captain said, however, that immediately prior to ditching, the fuel flow of the Nos. 1 and 2 engines appeared to be low. Approximately two minutes after the fuel dump valves were opened, the landing was made The crew said the landing was made tail low and was not considered sufficiently rough to damage the aircraft; however, prior to leaving his seat, the first officer looked out of his window and saw the aircraft's tail section floating in the water, It was later found that the tail section had broken off behind a bulkhead to the rear of the cabin door. Although heavy seas were running at the time of the accident, non of the seats were torn from their fastenings Three twenty-man rafts and one ten-man raft were carried on board the aircraft as a part of the life-saving gear. These were stowed in an open rack to the rear of the pilots' compartment. In addition to the life rafts, a pneumatic life jacket was available for each passenger. These jackets were located m a pocket on the back of each seat. Above each pocket was a sign, in both Spanish and English, describing the location of the jackets. According to the testimony of the purser and steward, they were seated in the rear of the aircraft when the second officer returned to the main cabin the second time and by a downward motion of his hands indicated the aircraft was about to be ditched* Although they did not hear this crew member say anything, they understood that ditching was imminent, made certain their seat belts were fastened, and donned their life preservers, After the aircraft contacted the water, they shouted to the passengers that the life jackets were located m the backs of the seats and then proceeded forward, opened tne two emergency exits on the left side of the cabin, climbed out on the wing and assisted passengers through these exits. The passengers were not told where the jackets were located or instructed in their use by any crew member prior to ditching. As a result, considerable confusion occurred. The second officer was able to loosen a twenty-man raft from its moorings m the pilots compartment and carry it to the mam cabin where he launched it tnrough a forward emergency exit on the right side of the aircraft, through which he also departed. The first officer and a woman passenger tried to loosen additional rafts, but were unsuccessful, and because of the rapidly rising water were forced to abandon ship, both departing through the right cockpit window. Immediately following the ditching the captain went into the cabin and ordered the passengers to abandon ship; however, there was very little response. He then aided a passenger to open the main cabin door, and began forcibly evacuating passengers through that exit. While so engaged, the door slammed closed, and the captain gripped the handle in an effort to open it again, but as he did so a wave caught the door violently pushing it out- ward, throwing him into the water. Du to the heavy seas, he was unable to return to the aircraft. Of the 12 passengers who survived, seven evacuated the aircraft through emergency cabin exits, four through the main cabin door, and one through the right cockpit window. The first and second officers boarded the only life raft launched, and took aboard five surviving passengers, the purser and the steward. The captain and seven other passengers were picked up by rescue aircraft after floating in the water from thirty minutes to an hour. "When the U. S. Coast Guard Rescue Coordination Center was advised that the aircraft might ditch, they immediately prepared for action. A Coast Guard PBY amphibious aircraft was alerted to prepare for rescue operation, and a few minutes later was dispatched to the scene. The U. S. Coast Guard cutter Bramble, together with a Navy tug, and other smaller surface craft also proceeded to the scene. An additional PBY aircraft was ordered out, as were two SA-16 amphibious aircraft of Flight C, First Air Rescue Squadron, U. S. Air Force, from Ramey Air Force Base, Aguadilla, Puerto Rico. One Coast Guard aircraft and two Air Force aircraft landed and engaged in the rescue activities. Other aircraft, including the Air Force C---li7 which had observed the ditching, circled the area to coordinate the rescue activities, drop flotation gear, and spot survivors. Seventeen survivors and a number of bodies were picked up by the crews of the rescue aircraft and the Bramble. Rescue activities were greatly hampered by the heavy seas, the waves being 10 to 15 feet high. Aircraft in the air spotted a number of sharks in the vicinity of persons in the water, and shark repellent was dropped* On April 10, tne day prior to the accident, the aircraft involved was flown from New York International Airport to San Juan as Flight 27 Captain F. Ee Mams, the pilot-in-command of this flight, stated that afxer departing the ramp at New York and during the engine run-up, No, 3 engine did not function properly. At this time it was noticed that the left magneto of this engine was completely deaa. fne aircraft was returned to the ramp for magneto service, after which tne engine functioned m a normal manner. During the run-up, no unusual engine noises were heard, ana the oil pressures, fuel pressures, ana fuel flow, etc., were within operating limits. During the takeoff and climb the aircraft appeared to fly normally m every respect and with all engines running smoothly. After flying for approximately two hours and thirty-five minutes, No. 3 engine began running roughly. A short time later the engine oackfired, and its propeller was feathered. Considerable difficulty was experienced m keeping the propeller in this position. Captain Mams further stated that the indicated fuel flow for the three operating engines was below what he expected and he noted this condition in the air- crafts Maintenance Log* Pan American World Airways employs a chief mechanic, several assistant chief mechanics and an adequate crew of mechanics to perform all necessary maintenance at San Juan* In the event it is necessary to change an engine at this base, it is done upon advice from Miami. Upon the arrival of Flight 27 at San Juan on April 10, the aircraft was taken to the maintenance hangar for repair, and the right magneto on No. 3 engine was replaced. The fuel flow gauges were checked, and a comparison between the No. h gauge and the No. 1 and No. 2 gauges showed that No. h. was registering 20-2 pounds low. No entry of this discrepancy was entered on the log sheet. As a precautionary measure, the Noe 3 engine oil sump and screen were checked. Small metal flakes were found on the screen, and a similar flake was found on the sump plug. These metal flakes were tested by using a magnetized screw driver and were believed to be aluminum. During the run-up of the engine, the mechanic heard a scraping noise which appeared to come from the nose section. The assistant chief mechanic immediately checked the log and noticed that difficulty had been experienced m feathering the propeller on the last flight As he was going off duty at this time, due to a routine crew change, he passed this information on to the next assistant chief mechanic relieving him. The new crew ran No. 3 engine for approximately two minutes and because of the unusual noise m the nose section stopped the engine. The nose section was removed, and additional metal flakes were found in the lower part of the nose section housing, Mechanics were assigned to remove and check the sump plug and oil screen, As a result of this inspection, metal flakes were again found m the sump . A mechanic tnen drained and cleaned the oil tank and hopper Examination of the hopper revealed the presence of approximately a teaspoonful of metal flakes, These flakes were tested by use of a magnetized screw driver and sulphuric acid; and in the opinion of the mechanics who made these tests, the flakes were aluminum. (The use of sulphuric instead of nitric acid to determine the composition of the metal flakes was not in accordance with the procedure outlined m the company's Maintenance Manual. The manual describes the reaction of certain metals to nitric acid, and the only similarity to these reactions when sulphuric acid is used is when the metal is aluminum.) The nose section itself was not disassembled; however, it was given a cursory examination and a mechanic stated that a bearing was damaged Also, flakes of metal were found in the bottom of the nose section. A mechanic placed his fingers through tne opening to check the scavenger pump drive gears and found metal flakes inside next to the gears. These findings were called to the attention of the assistant chief mechanic. The chief mechanic was not on duty when this work was done; however, had the assistant chief mechanic considered the matter of sufficient import the chief could have been contacted, since he was subject to call at all times. The assistant chief mechanic did not consider this course of action necessary and according to company policy sent the following message to the company's Miami office: "OXMIA MJMIA OWSJU N88899 #3 ENGINE FEATHER STAGE L DUE ROUGH RIGHT MAGNETO STOP SAND FOUND ALUMINUM SHAVING ON SUMP STOP FLUSH ENGINE CHANGED OIL CHANGED RIGHT MAG STOP ON R/W FOUND BAD NOISE ON NOSE SECTION STOP PROCEDING CHANGING NOSE SECTION STOP WILAD AFTER R/R MASJU 1105^0" In effect, this message means that he was changing the right magneto, that he had found aluminum flakes m the sun?} and oil screen, and that he was flushing the engine and changing the oil; also, because of a noise the nose section was being changed. Miami did not acknowledge receipt of this message or issue any instructions. According to the testimony of the mechanic, since nothing was heard from Miami, he considered that he had approval to proceed as stated. The company's Maintenance Manual specifically states that when foreign material such as aluminim, is found m the sump, etc., the following course of procedure is to be followed: "The entire oil system, including oil tank ail radiator, oil temperature regulator and oil pump, must be thoroughly cleaned and flushed, or replaced, including the accessory section screen. Put about 10 gallons of oil in the tank and run the engine for about one-half hour, bringing it up to take-off power once for five seconds only during this period. Drain oil, clean the strainer screen and fill oil tank to proper level. Run up engine again, pull screen and sump plug, also the small screen located between the oil pump and vacuum pump on the accessory section. If all right, release for flight." When the nose section was changed, the above procedure was not followed in that the specified engine run-up with only 10 gallons of oil in the tank was omitted. The purpose of this run-up with but 10 gallons of oil is to accomplish a more efficient flushing of the engine's oil passages, thereby depositing any additional metal flakes in the oil to be drained or on the oil sump plug and screen. By eliminating that part of the prescribed procedure this additional check was not made, and a necessary one-half hour of engine run-up time was lost. Instead, oil was placed in the tank to the full level, and the engine was then run up for a few minutes and appeared to function properly, The oil sump plug and screen were then checked, and since no flakes of metal were found, the engine was released for service. Subsequent to the accident, the nose section which had been removed was disassembled and examined by the Boards investigators, and certain parts were removed and forwarded to the Washington office for further examination and study. This examination revealed that the reduction drive gear bearing had partially failed. Failure of this bearing allowed the reduction drive gear teeth to move partially out of mesh. Continued operation in this condition would eventually result in complete failure of the reduction gear assembly. The six sludge cups from the No. 3 engine propeller reduction gearing were forwarded uo Washington, where the contents of these cups were given a spectrographic examination at the U. S. Bureau of Standards. This ex- amination showed that metal particles were concentrated m the upper 1/32- mch layer of the sludge; and when these metal particles were separated, it was found that the major constituents were silver and iron. The minor constituents were copper, indium, chromium, manganese, nickel and lead. With the exception of the lead, which is an anti-detonating agent of the fuel that does not burn, all constituents were materials used in the manufacture of the engine. The remainder of the sludge below the 1/32- inch layer had lead as its major metallic constituent As the aircraft was departing the ramp, the log was placed aboard, which was the first time that information was available to the crew that the nose section of No. 3 engine had been replaced; however, none of the crew checked the log before take-off. The Latin American Division of Pan American World Airways maintains a flight and ground training school at its Miami Base. All flight training is taught by professional instructors. These instructors devote their entire attention to pilot instruction and do not fly the line. Captain Burn was employed by Pan American World Airways as a co-pilot September 9, 191*2, and checked out as co-pilot on DC-1* aircraft June 27, 191*6 In the fall of 1950 he was trained for 35 hours in the Dehmel trainer and received several hours' training m a Boeing 377 aircraft, following which he served as a co-pilot on this type aircraft for a period of approximately one year. In January of 1952, Captain Burn completed his ground school training and 18 hours of flight training on DC-1* equipment. This was given as transition training from co-pilot to captain. On January 9, 1952, upon completion of his transition training, Captain Burn was recommended by his instructor for pre-command and type rating checks on DC-1* aircraft. As a result, on this date Captain Burn was given both an oral examination and a flight test by the Chief Flight Instructor, who, feeling he needed additional time, flew with him on the two following days, after which he was given the necessary ratings. Captain Burn had flown approximately 208 hours as pilot-m-command in DC---li equipment prior to the accident. A review of the aircraft's records indicated that prior to departing this flight, the engines had the following total time since last overhaul Nos. 1, 2 and 4 engines, 1256:24, and No. 3 engine, 1122:11. In the Maintenance Log, under "flight entries," were several comments which indicated that the aircraft was sluggish in climbing. In each instance, the aircraft was below the allowable gross weight. Other comments reflected fuel flow below normal and considerable magneto trouble The log, under "Maintenance and Service," indicated that the fuel flow items were "continued to Miami." Analysis Only a minor trim correction for yaw was required from the time the propeller was feathered on No. 3 engine until the aircraft was ditched. This was true despite the fact that during certain portions of the flight 9 take-off and maximum power were used on Engines Nos. 1 and 2 During these power settings, No. 4 engine was set at 32-35 inches of mercury. From this it can be seen that the No. 4 engine was producing considerable power, otherwise, there would have been a decided yawing moment when power was increased on engines 1 and 2. It has been established by flight tests that the DC-4 aircraft loaded in a like manner will maintain level flight, and climb slowly, with only two engines operating at a maximum continuous power and with the propellers of the remaining two engines feathered. Therefore, the aircraft, under the conditions described, should have at least maintained altitude. Referring to the Performance Chart m DC-4 CAA Approved Flight Manual, it is noted that with altitude and temperature, etc., corrected to the conditions surrounding this accident, and with two engines operating at maximum continuous power, propellers of the remaining two engines feathered, the aircraft will climb at the rate of approximately 25 feet per minute. Also, with three engines operating at maximum continuous power and the fourth engine's propeller feathered, the aircraft will climb at approximately 400 feet per minute. Engines which have considerable time in service may suffer a loss in power. All of the engines involved had approximately 1200 hours of service since overhaul. As the engines were not equipped with torque- meters, it was impossible to determine accurately what their actual power output was on this flight. However, even assuming that there was a loss of power due to time in service, it is difficult to understand how the accumulated power of the three engines operating as stated could be less than that from two good engines operating at maximum continuous power. Throughout the flight and the subsequent ditching, the captain stated he followed the prescribed procedures outlined m the company's Operation and Flight Manuals. He said that, after feathering the No. 3 propeller, he established an air speed of 145 miles per hour throughout the climb but after experiencing difficulty with No. 4 engine he then established an air speed of 135 miles per hour m an effort to climb Obtained from RareAviation.com. See our selection. Copyright (c) 2004 *> at the maximum rate. Although the companys Flight Manual states tnat these air speeds are correct for 3-engme and 2-engine operations, respec- tively, this applies to aircraft equipped with horsepower engines than those on this aircraft. The manual also states under Engine Failure1 and During Climb After Takeoff, ' should an engine fail after power has been reduced to climb power or at any time after takeoff, set power on good engines to rated power or takeoff if necessary,, After power has been increased, the engine feathering procedure should be completed. Captain Burn said that after he had established air speed of 135 miles per hour, the aircraft continued to lose altitude, and that the two good engines were not increased to take-off power until he decided to dump fuel. Since it was established tnat the fuel dumping operation was started approximately two minutes prior to the landing on the water, it can be seen that a considerable period of time was dissipated m attempting to climb at rated power* In an emergency such as this, where the maximum altitude involved was only 550 feet, it would seem that good flying technique would not permit a loss of air speed by maintaining a continuous nose high attitudeThis could well have meant tne difference between maintaining level flight and losing altitude. The attendants were not advised m sufficient time that the aircraft was to be ditched for them to adequately prepare the passengers for a water landing. When the second officer first came to the cabin, he told the attendants to close all electrical circuits to prevent a possible fire as fuel was to be dumped. This was done, and according to the purser and the steward, they considered these instructions as routine and did not interpret them to use an a ditching was imminent, When the second officer next returned to the cabin, they could not hear him from where they were seated, but from his actions they knew the aircraft was to be ditched- They immediately put on their own jackets but made no attempt to warn the passengers. Additional lives might have been saved if previous instructions had been given the passengers m the location and use of the jackets. The companys policy of stowing all life rafts in. a single compartment to the rear of the pilots does not permit ready accessibility, In this location they are available only to the crew, and because of the close quarters in this section of the aircraft, they cannot be readily launched# In this instance, only one raft could be released from its moorings, as a second raft was jammed when attempts were made to release it. If more life rafts had been readily available, additional lives might have been saved. I The mechanics at San Juan wno performed the service on the No. 3 engine and changed this engines nose section said that all work done by them was performed as prescribed m the companys Maintenance Manual. The assistant chief mechanic, however, did not consider it necessary to change the engine, althougn a large quantity of metal flakes was found m the oil hopper, etc Tnis aid not necessarily mean that these particles had traveled through tne enginej however, it did mdiCAte that some part or parts of the engine had failed. To determine the extent of this failure., the engine snould have been further disassembled. This was not done. Instead, a nose section was installea desnite considerable evidence of metal particles m the old nose section and the lower front of the power section of the engine. A dispatch describing the action being taken was then sent to the companys Miami office. That office, having received this information, should have issued instructions to San Juan that this engine be changed. Due to the condition of the No. 3 engine, the aircraft was not airworthy when it departed San Juan. The analysis of the contents of six sludge cups from this engine's propeller reduction gearing definitely showed particles of metals other than aluminum. The top l/32~mch of sludge was predominantly silver and iron, whereas the major metallic constituent of the remainder of the sludge was lead The rate of ueposit of material can be expected to increase in the event of a progressive failure m the engine. Therefore the silver and iron deposit m the top 1/32-mch of sludge indicated that a progressive failure was occurring. The ab^ve reasons ng is in accord with the observed wear pattern on the propeller reduction pinions and drive gear. The evidence indicates that tne maintenance operations of this carrier at San Juan were not conducted in accordance with the high standards re- quired for airline operation. As a result of this and similar accidents the Board has proposed amendments to Parts U0, hi, h.2 and 61 of the Civil Air Regulations with relation to emergency and evacuation equipment and procedures, to assure a greater degree of safety to the occupants of aircraft flying over water routes. It has been found that accidents have occurred when there was insufficient time to adequately plan and prepare for a ditching. Among others, the following amendments to the Board's regulations have been proposed: 1# All required rafts and life vests shall be approved, shall be adequately equipped for the route to be flown, and shall be installed m approved locations They shall be readily available and easily accessible to the crew and passengers m the event of an unplanned ditching. 2. In the case of extended overwater operations each air carrier shall establish procedures for orally briefing passengers as to the location and method of operation of life vests and emergency exits and the location of life rafts. Such briefing shall include a demonstration of the method of donning a life jacket. Such briefing shall be accom- plished prior to take-off on all extended overwater flights on which the aircraft proceeds directly over water. On flights not proceeding directly over water, the briefing shall be accomplished some time prior to reaching the overwater portion of the flight. The Board is continuing studies of problems relating to aircraft ditching and evacuation 11 - Findings On the basis of all available evidence the Board finds that: 1, The carrier, the aircraft and the crew were properly certificated. 2. Weather was not a factor in this accident. The company's maintenance department at San Juan should have been alerted to a dangerous condition when metal particles were found in the nos section of No. 3 engine. Pan American's Miami office, having received information regarding the No 3 engine from the maintenance department at San Juan, should have issued instructions to San Juan that this engine be changed Due to the condition of No. 3 engine, the aircraft was not airworthy when it departed San Juan. 6. No. 3 engine failed immediately after takeoff, which was followed by a partial loss of power from No. h engine. The captain demonstrated questionable flying technique under the existing conditions. Probabl Cause The Board determines that the probable cause of this accident was (a) the company's inadequate maintenance in not changing the No. 3 engine which resulted in its failure immediately subsequent to takeoff, and (b) the persistent action of the captain m attempting to re-establish a climb, without using all available power, following the critical loss of power to another engine. This resulted in a nose-high attitude, progressiv F- loss of air speed and the settling of the aircraft at too low an altitude to effect recovery. BY THE CIVIL AERONAUTICS BOARD: /s/ DONALD W. NYROP /s/ OSWALD RYAN /s/ JOSEPH P. ADAMS /s/ CHAN GURNEY SUPPLEMENTAL DATA The Miami office of the Civil Aeronautics Board was notified of this accident by Pan American World Airways in Miami at approximately 113$ EST April 11, 1952. An investigation was immediately initiated in accordance with the provisions of Section ?02 (a) (2) of the Civil Aeronautics Act of 1938, as amended. A public hearing was ordered by the Board, and was held in the Public Amusement and park Administration Building, Ponce De Leon Avenue, Parada 8, San Juan, Puerto Rico, on May J, 1952. Air Carrier Pan American World Airways, Inc is a New York corporation, having its main offices at 135 East U2nd Street, New York City, and operates as an air carrier under a certificate of public convenience and necessity and an air carrier operating certificate issued pursuant to the Civil Aeronautics Act of 1938, as amended. These certificates authorize the carrier to engage in air transportation with respect to persons and property between various points in the United States and foreign countries, including San Juan, Puerto Rico. Flight Personnel Captain John C. Burn, age 33 9 was employed by Pan American World Airways September 9, 19b-2. He was the holder of a valid airman certificate with an air transport rating, Captain Burn had a total of 6,920 flying hours, of which h,995 were in DC-h equipment - He was qualified to fly as captain m DC-b aircraft January 11, 1952. He nad a total of 208 hours as pilot-in-command of DC-4 aircraft prior to the accident His last inst r ume nt and equipment check was accomplished January 11, 1952 and his last route check was on January 18, 1952. Captain Bum received his last CAA physical examination on February 27, 1952 First Officer W. T. Hutchins, age 30, was employed, by Pan American World Airways on February 15, 1951* He held a valid airman certificate with commercial pilot, single and multi-engine land, flight instructor and instrument ratings. He had a total of approximately 5,000 flying hours, of which 708 were m DC-b equipment. His last instrument and equipment check was accomplished March 26, 1952 and his last CAA physical examination November 19, 1951. Second Officer J. R. Laubach, age 3b, was employed by Pan American World Airways, October 29, 1951. He held a valid airman certificate with commercial pilot instrument and flight instructor ratings. He had a total of approximately 2,000 flying hours, of which 5b were in DC-b equipment. His last instrument and equipment check was accomplished February 13, 1952, and his last CAA physical examination April 23, 1951. Purser A. Perez was employed by Pan American World Airways on April b, 19b6. Steward R. Torres was employed by Pan American World Airways on July 2, 1951. --- J Wib The Aircraft N88899, a Douglas DC-ii, was owned and operated by Pan American World Airways and was currently certificated by Civil Aeronautics Administration. It had a total of 20,835 flying hours, of which 1,5111 were accumulated since overhaul, and was equipped with Pratt & Whitney R-2000 engines and Hamilton Standard 23E-5O propellers. --- ii " 3A-314 File No 1-0145 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted: April 30, 19% Released: May 3, 1956 PENINSULAR AIR TRANSPORT, DOUGLAS C-54-DC, N 88852 SEATTLE, WASHINGTON, NOVEMBER 1?, 1955 The Accident At approximately midnight^/ November 17, 1955, a Douglas 0-54-DC, N 88852 operated by Peninsular Air Transport, crashed in a residential area of Seattl J Washington. The accident occurred immediately following takeoff from Boeing Field. Of 74 persons aboard, 28, including a third pilot, were fatally injured The remaining 46, including other crew members, received injuries of varying degree. Although there were no injuries to persons on the ground, the accident caused substantial property damage The major portion of the aircraft was destroyed by impact and fire. History of the Flight Peninsular Air Transport Common Carriage Flight 17K was scheduled to originate at Boeing Field and terminate at Newark, New Jersey, with intermediate refueling stops. The assigned crew consisted of Captain W. J. McDougall, First Officer F. C. Hall, and Steward J. 0. Adams. The third pilot, Edward McGrath, deadheading to Miami, Florida, occupied the jump seat with no crew duties. Die flight, scheduled to depart at 2030, was delayed because of a heavy snowfall during the afternoon and early evening of November 17 which delayed passenger arrivals and necessitated removal of snow from the aircraft before departure. At 2332 the flight taxied to runway 13, holding off the xunaay waiting its turn behind other flights to take off. During this tune the crew completed pretakeoff checks and received an IFR (Instrument Flight Rules) clearance, b in part, instructed them to turn right after takeoff and climb on the northwest course of the Seattle Range to 5,000 feet m. s. 1. (mean sea level). The takeoff was started at 2358 and appeared normal as the landing gear retracted and right turn was begun, When approximately 300-400 feet above the ground the first reduction of power, from takeoff to normal rated power, was made and about five of the 15 degrees of flaps extended, were retracted At this tine the No. 4 propeller surged and engine r. p m. increased to about 2,800 Unable to reduce the r. p. m. of No. 4 by reducing its power an attempt was made to feather the propeller; this also was unsuccessful As the aircraft then began to descend takeoff power was reapplied to Nos, 1, , and 3 engines and the power from No. 4 was further reduced b Srl9 U r. p. m. of No. 4 which surged again and increased to more than 3,000. Th aircraft veered to the right and continued to descend. Realizing that a 1/ All times herein are Pacific standard and are based on the 2h~hour clock. COMM-DC-65O64 crash-landing was imminent Captain McDougall reduced the airspeed until the aircraft was nearly stalled and applied full power to all four engines. Th aircraft continued to settle. It then struck a telephone pole and several trees before crash-landing in a nose-high attitude. Fire and rescue equipment was dispatched to the scene from both the Seattle Fire Department and the Seattle-Tacoma Airport. The units arrived promptly and gave first aid to the survivors. Fire which followed the crash was quickly extinguished but not before extensive property was burned and the aircraft was nearly consumed. Investigation The accident scene was located approximately 2-1/2 miles from and 300 leet higher than the takeoff position of the flight. Evidence showed the aircraft was banked to the right when it initially struck the telephone pole with its right wing and horizontal stabilizer. Continuing along the impact heading of 210 degrees it cane to rest approximately 6$0 feet beyond the pole. Along this path the aircraft struck several buildings, trees, and another pole, causing separation of both wings and tail and severe damage to the fuselage. The fire which broke out after final impact consumed major portions of the structure. Examination of the remaining portions of the wings, fuselage and tail disclosed no evidence that indicated structural failure or malfunction prior to impact. Both pilots stated they had experienced no difficulty except that associated with the No. 4 engine and propeller. The four powerplants, including their accessories, were located within a relatively small area. Each had been separated from its mount and its npse case torn off. All had been exposed to the resultant fire which consumed their rear magnesium cases. The propellers were found attached to their respective propeller shafts and Nos. 1 and 4 were not damaged by fire , Te ardown inspec- tion of Nos. 1, 2, and 3 engines and propellers disclosed no evidence to indi- cate they were factors in the accident. The No. 4 propeller, attached to the engine nose section, was located about 2$ feet from the main wreckage. There was oil covering its barrel, the face side of all propeller blades, and the engine nose section. Examination disclosed that the propeller dome retaining nut protruded approximately one- eighth of an inch above the barrel dome bore and the safety cap screw was pressed against the corner of its safetying recess, The lock screw was safetied. The screw was removed and its examination showed no evidence of bending or mutilation. After the nut and barrel were marked to show their original positions a check was made for tightness. The result showed the not could be moved with comparative ease with a small drift and hanmer for at least 4-1/2 inches in the tightening directio: least 4-1/2 inches in the tightening direction. The nut was then unscrewed and the dome removed to check the propeller blade pitch settings as indicated by the cam gear position. This revealed the cam gear lug was against the low pitch stop, or the normal low pitch blade angle setting The : gears were marked to show their positions in relationship to each other and to the cam gear. The propeller assembly was then further disassembled and examined after which it was removed from the accident scene for continued examination and testing. Examination was directed to ascertain the individual blade angle settings This disclosed that all of the eight spring packs which retain the segment gears, with their respective blades, were mutilated and displaced such that this retention was destroyed. Each of the segment gears was fractured at one of the spring pack recesses. This permitted free rotation of the blades about their longitudinal axis; however, the cam gear prevented any movement of the segment gears, enabling the investigators to determine the individual blade position at impact. Examination showed that the fifth valley from the low pitch end of the segment gears was lined up with the center etched line on the barrel bore for the Nos. 1 and 2 blades. The Nd, 3 blade segment gear, however, had the sixth valley lined up with the etched mark. This showed that the Nos. 1 and 2 blades were positioned one segment gear tooth less, or eight degrees less, than the Nd, 3 blade. Compared to the low pitch stop the No. 3 blade was positioned at 24 degrees, the normal position, while Nos. 1 and 2 blades were at 16 degrees, eight degrees less than the normal position. To determine the possibility of oil leakage and, if existent, the amount of leakage from the loose dome assembly, the propeller was reassembled using replacement parts only where necessary; the dome and barrel assembly from the original propeller were used. The exact dome looseness was duplicated on a propeller test stand and oil was pumped into the propeller assembly at various pressures* The tests revealed that there was oil leakage at all pressures and that the maximum oil pressure obtainable was 200 p. s. i. (pounds per square inch) scause of an 18-quarts per minute oil leakage past the loose dome At this time the pump was operating under test conditions which would normally produce about 600 p. s, i. The test further showed the oil supply of the engine would rapidly be exhausted . (Oil capacity per engine is 20 gallons.) The No. 4 engine was examined in detail. This revealed that the rear master rod bearing was in the process of failure. It also showed the front master rod bearing was beginning to fail. Examination of the bearing failu showed they were characteristic of those associated with oil starvation. Neither, however, had progressed to the extent that it would be expected to appreciably affect the operation of the engine or its power capability, I me engine examination disclosed no other evidence of malfunction or failure According to company witnesses and records, the No. 4 propeller had been overhauled September 7, 1955, and thereafter installed on another company DC-4. On November 11, 1955, it was removed as a result of a pilot roughness complaint applying to it or the No. 4 engine. The propeller was examined, repaired, and tested, after which it was installed by Peninsular maintenance personnel on N 88852 in the No. 4 position. Maintenance personnel stated a new propeller dome seal was used during this installation. At the time of the accident the propeller had accumulated 475 hours since the major overhaul and 20 hours since its installation on N 88852. During a portion of the 20 hours, the aircraft was flown to Kansas City where Captain McDougall took command of the aircraft and continued a military contract flight to McChord Air Force Base, Tacoma, Washington. This flight was uneventful except for a failure of the No. 4 starter solenoid at Billings, Montana, Because there were no adequate repair facilities there to correct this problem the passengers were offloaded and the engine was started by talcing off on three engines and airstarting the No. 4 engine. According to the crew, snow on the runway made it inadvisable to start the engine by fast taxi since it was doubtful if the aircraft could have been stopped safely thereafter on 411 After arrival at McChord Air Force Base on November 13, 1955, the aircraft was immediately ferried to Boeing Field where Captain McDougall contacted the Seattle Aircraft Repair, Inc., a repair agency under contract to do certain maintenance for Peninsular, to replace the Nd. U starter solenoid, and to correct several other discrepancies noted and/or written up during the previous flight Captain McDougall instructed the repair agency to examine the No. 4 engine to be sure it was not damaged in any way by the airstart crew noted an accumulation of oil on the right wing in the area of the engines and brought it to the attention of maintenance personnel for corrective action* Without cleaning the oil from the aircraft and running the engines to determine the source of leaking oil, the employees concluded from visual inspection that the leak came from the Nos. 3 and 4 propeller dome seals. During the public hearing the mechanics and helpers who worked on the air- craft, and particularly on the No. 4 propeller, were called to testify. These witnesses were employed by Seattle Aircraft Repair, some working as part-time employees and others as full-time, In connection with the personnel working on the No. 4 propeller, the helper had recently been employed and the CAA certificated mechanic in charge had not replaced dome seals for three years. Neither employee was familiar with the experience and capability of the other or the prescribed procedure to be followed in correctly replacing the dome seals. These witnesses, through their testimony, showed there was no clear line of responsibility within the company nor were there reference manuals to define their specific work procedures. Witnesses testified that the work on the No. 4 propeller was done under adverse weather conditions* It was accomplished outside in very cold weather and with considerable snow falling. The two employees who worked on the No. 4 propeller, an A&E mechanic and a helper, said that an accumulation of oil was evident under the right wing and around the propeller W<( domes were removed and, according to testimony, the No. 4 seal was found gougea New seals were then obtained from the company supply, wanned, and The mechanic helper said he assisted in placing the installed in the domes. The mechanic helper said he assisted in placing the No, 4 dome in position, turned the dome retaining nut on a few threads, and left the job to go home. The employee in charge of this work said that with the assistance of his helper he tightened the dome retaining nut with a dome wrench. He further stated that he was satisfied it was tight and that he had replaced and saf etied the lock screw. Testimony of the witnesses clearly showed that during the work the propeller was not feathered, as required by good practice, and the positions of the blades were not checked either before the seal was installed or after the work was completed, An inspection of this work was made by an authorized employee but consisted only of a check to see if the lock screw was safetied. It was also learned that neither this engine nor any of the others was run up at any time to determine the adequacy of the maintenance. While the maintenance work described was m process, a No. 1 inspection Peninsular Air Transport officials from Miami. This was com--- pleted, according to numerous witnesses however, the records were apparently destroyed, being aboard the aircraft when it crashed. Company Instructions required that one copy of the inspection be mailed to the home offices how- From ever, Captain McDougall did not do this but instead put all the records in the flight log. Testimony of the flight crew indicated that they arrived at the Boeing Airport about 1900, November 17. They stated that they went to the Seattle Aircraft Repair office and were unable to contact anyone who could inform them concerning the work performed on N 88852, or the readiness of the aircraft for flight. They returned to the terminal thereafter and began preparation for the flight, contacting the weather office and completing other necessary details Another trip to the repair agency office was made with the same results as the first, after which they again returned to the terminal and found Mr. Aho, Vice President of Seattle Aircraft Repair. According to Captain McDougall and First Officer Hall he informed them that the aircraft was ready for flight and that all the maintenance work had been completed. The captain further stated he received the No. 1 inspection form, the daily flight check form, and the repair forms on the work he had ordered. Although not sure who had told him, Captain McDougall said he was told that the engines had been run up. He further stated that the forms given him indicated the engines had been run up and that the aircraft was signed off as airworthy by Mr. Aho. The crew testi- fied that following this they went to Seattle Aircraft Repair to get their aircraft. They performed a walk-around inspection, noting that the evidence of oil had been cleaned from the No, U engine. They started all engines, running them at low r. p. m. for approximately 10-20 minutes until they were warm. The aircraft was then taxied to the terminal for loading. Mr, Aho testified that the crew did not contact him until after the air- craft had been brought to the terminal Ee stated the crew brought the craft there without knowledge of whether it was ready and without having the various work forms. The witness indicated that the engines were not run during the nonroutine maintenance work on the propellers. He added that following the type work accomplished on the No. U propeller a runup would normally b required. Following the other work, the daily inspection and No. 1, the runup was not done because of the extremely heavy workload upon his organization. He added that the forms given the crew did not indicate the engines had been run and the subject was not mentioned during any converse tion with the Peninsular crew. Mr. Aho said he signed the forms given the crew, indicating the aircraft was airworthy. Captain McDougall stated that the aircraft was covered with considerable snow and it was necessary to have a crew remove it. The flight crew, several passengers, and personnel who cleaned the aircraft all agreed that it had been thoroughly cleaned before departure Records pertaining to planning and load distribution of the flight indi cated the flight was correctly and completely planned. They showed the air- craft was loaded to a gross weight of 61,138 poundsj the maximum allowable takeoff weight was 62,000 pounds. According to the records the weight was properly distributed with relation to the center of gravity of the aircraft. There were 1,200 gallons of fuel aboard which was sufficient for the flight in accordance with instrument rules. The crew and many other competent witnesses stated that weather conditions were substantially as reported by the Weather Bureau - ceiling 1,600 feet broken, 2,300 overcast, visibility 7 miles. The crew said that after the air- craft was cleaned of snow there was no precipitation and thus no chance of ice forming on the aircraft. The weather observer stated that in his observations during the period between 2300-2400 he carefully watched for signs of freezing rain but there were none. Other aircraft crews who departed just ahead of the accident flight found no icing before or during takeoff. Captain McDougall said that visibility was good, that weather conditions did not affect the course of his action, and that at no time was the aircraft high enough to encounter the clouds. The crew stated the pretakeoff checks were comprehensive and were completed while waiting their turn to take off and just after taking position on the run- way. During the checks the engines were run up to approximately barometric pressure (30 inches of manifold pressure). Nos, 2 and 3 engines were run up together and then Nos. 1 and 4 together. The crew said no roughness was ob- served or felt. Copilot Hall stated he used the ice light to observe Nos. 3 and 4; however, Captain McDougall did not recall it being used. The propellers were exercised at least four tunes before the response was normal for Nos. 3 and 4 propellers. The customary feathering checks were made. Captain McDougall testified that he made the takeoff from the left seat. As was his habit under the existing conditions, control of the aircraft was accomplished principally by reference to instruments. Both pilots agreed the takeoff and climb were normal until the first power reduction, 300-400 feet above the ground, at an airspeed of approximately 120 knots, and with a rate of climb of between J>00 and 1,000 feet per minute. The captain felt the air- craft yaw to the right when the No. 4 r. p. m. surged at the first reduction of power and again when the power on No. 4 was reduced The rate of climb imedi ately decreased and as the engine and propeller began to overspeed an unsuccess ful attempt to feather was made Both pilots noted a reaction from the propeller and momentarily it appeared that the propeller was feathering The copilot said he noted a reduction m r. p. m. to about 1,^00-1,800 which Captain McDougall said he felt when the yaw was momentarily relieved, Takeoff power was added to all but No. 4 engine. Immediately thereafter the r p. m. of No. 4 increased to more than 3,000 which, after consideration, the copilot felt was nearer 3,500. This was accompanied by a loud propeller whine, heard by the crew and numerous persons on the ground. The copilot said he felt the feathering button which was still in, the position to actuate feathering. He pulled the button out, pushed it back in, in a second attempt to feather; there was no response. Captain McDougall stated that the aircraft was descending during this tune, and he raised the nose of the aircraft in an attempt to hold alti- tude at a slower airspeed* The captain related that he did not use trim to alleviate the heavy yaw, stating he could hold directional control without trim and he was better able to feel his aircraft without it. He also stated that the No, 4 propeller drag felt insurmountable and it was impossible io gain or even hold altitude. Captain McDougall then concentrated on crashland- ing the aircraft with as slow an airspeed as possible and in the least populated area. He therefore allowed the aircraft to turn away from a hill toward a flatter area. Both crew members said full power was applied to all engines and the aircraft hit tail first in a full power stall. Eyewitnesses who described the flight were principally in agreement with numerous important factors and these support the observations and action of the crew. Several witnesses saw and heard the aircraft take off and stated that it appeared and sounded normal. Some of the witnesses described the overspeed- ing sound which reached a high-pitched whine. An experienced mechanic said, having heard the overspeed sound before, he recognized it immediately when N 88852 passed his position. He also said that saw No. 4 engine torching badly and it appeared that the exhaust flame was being fed by oil Several witnesses described the aircraft as flying in a considerable yaw to its right, and another saw it turn right to avoid the hill as described by Captain McDougall. There was a roar of increased power just before impact and one witness stated that the aircraft crashlanded in a nose-high attitude. Most witnesses were in agreement that weather conditions were similar to those re- ported, stating that it was snowing very little, if at all, and there was no freezing ram. Daring +he public hearing a qualified representative of the propeller manufacturer, Hamilton Standard, testified concerning the drag which would be expected from the improperly indexed propeller blades of N 88852. The witness stated that according to engineering data under the following conditions, blades properly indexed at 24 degrees, sea level condition, airspeed 115-150 fl u p. h., engine r. p. m. 1,586, propeller drag was 570 pounds. Under the same conditions except with the propeller blades indexed as found on the acci- dent aircraft, two at 16 degrees and one at 24 degrees, the propeller drag was 1,360 pounds, or about 2.3 times greater. Testa were made to determine what, if any, roughness existed as a result of the improperly indexed propeller blades of the No. 4 propeller. The blade configuration of N 88852 was intentionally duplicated on an outboard propeller of another DC-4 Running that engine only, it was noted that vibration could be felt in the cockpit with noticeable swaying of the magnetic compass unit mounted by shock cords. The vibration was apparent around 1,000-1,200 r. p. a and was vi sn ally noticeable by watching the engine shake on its mount. The vibration was evaluated as severe at the aforementioned r. p. m., becoming less apparent with increased r. p. rc. In the experience of the testing group several instances of blade mis indexing were known, nearly all of which were discovered during ground runup of the engines. At least one similar condition on a like aircraft went unnoticed during flight operation. The Peninsular crew stated, that after reaching the airport on November 17 and talking with Mr. Aho they were assured the aircraft was ready for flight. They stated that the maintenance forms given them were reviewed and showed the work ordered had been done. Because of conflicting recollections it is not known tdien this occurred, before or after the aircraft was taxied to the terminal Testimony of the maintenance personnel showed clearly that at no time after the aircraft was received for maintenance on November 14 were the engines run up. The Board is of the firm opinion that such a runup was essential to a vital part of the work performed on the Nos. 3 and 4 propellers and a responsibility of the maintenance agency. This was important in order to determine if the dome seals had been properly installed and if there were any leaks. It was even more necessary 'because the maintenance pe