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: Pan American Airways Accidents - 1938 to 1988
Link: https://rareaviation.com/product/pan-american-airways-accidents-1938-to-1988

--- RAW UNFORMATTED TEXT BELOW ---

DEPARTMENT OF COMMERCE .Washington '           . s        .*                                                                                                                                                                                                                                          -       C . A-. . ' .  ; _  .  .. . ...*' . -,:- July 2, 1938                                                                                                                                                                       -:>> ". t                                                                                                                                                                                                                                                                                                   TtxREPORT OP AIRCRAFT ACCIDENT INVESTIGATION .Statement of probable cause concerning                                                                                                                               an. accident which           occurred to J an airplane of pan American Airways at                                                                                                                               Kingston, Jamaica            on April- z.             W*''"* Vr"<ra           I |R I              >.TO THE SECRETARY OF COERCE:G.C.T. at sea about 10 miles south- On April 25, 1938 at about 20:18 P.M.,        ------------------- east of Kingston, Jamaica, an airplane of United States registry while being operated in foreign air commerce carrying mail, passengers and express met with an accident resulting in the loss of the airplane but no                                                                                                                                                                                                                                                               injuries to passengers                                                                                                                                                                            f and crew and no loss of mail and cargo.On April 27, 1933, the Secretary of Commerce issued                                                                                                                                                                                                                                                                                                                                                                              an order appointing aBoard to investigate this accident. Pursuant to said, order                                                                                                                                                                                                                                                                                                                                                                             an investigation                                                   i.*-, I v^s,madc and in connection therewith, hearings vrerc held at liiamiApril 28 to 14ay 7, 1938, inclusive.                                                                                                                                                                                                                                   A transcript of the testiraony obtained at said hearings is transmitted hcrcv.ith for your information and for the rccordsof the Department.                                 f.The pilot of the aircraft, designated by the company as Captain, was Joseph H. Hart. Captain Hart holds a current Transport pilot's license (noth| .known, as a "certificate of competency") and the necessary ratings and                                                                                                                                                                                                                                                                                                                                                    route  *'qualifications. The report of his lust physical excminr.tion as requi                                                                                                                                                                                                                                                                                                                             The report of. his last physical examination as required by y                                                    * v.**< .. *z^. ..  . .  .4 ..   . -  s                        z                        -r.     -                                  ... / s                                                                                                                                                                                                                                                                                    ,           , z  ; the Department of Commerce and taken on January 11, 1938, showed him to                                                                                                                                                                                                                                                                                                                                                                                                                                    ty-. physically qualified. ...                                                                                                                                                                                                                                                                                                                                                                                                                                  ; y./k_ :                                         i Pilot Hort has a rccord^of; approximately : flying time,                                                                                                                                                    3vcr 500 hours of vhich v/crc on the type of equipment involve                                                                                                                                                                                            *                                                                              , - , He was thoroughly experienced over the route in question an'the type ofI operation involved. 7 Pilot Hart ,1^                                                                                                                                                                                                                                                                                                                                                                                                                                                            ;jO': to ;thc;/ Civil                                                                           ?./. zi5$y? c ' <  - a^WctHpAikbvc^ ij; 1937 but sncti b<^tifUJhtd: will be rpqpiiOb-a^i ^hoal date of. his current< license .                                v;?  * **  S             *                                                   . S                            * * *  * *               . *  *         * Z  ./ r  Z    b* Z Z. %>* A                                                                                                                                                                                  The co-pilot, designated                         by > the company -asjMi^t'                                                                                                                                                                                                          n y^irst                       a  current certifchaSpetehjhy^.                                                                                                               .......HisjlObbtS^y^ical;'^            to ken ch- liar ch 17^11938,/' him':Oyh'                                                                                                                                                                                                                                                                                   s                                                                                                                                                                       qualified, y Hbitesja\recprd.?bf- over^gCMS-hpurs                                                                                                                                                  59^9: as tdp^ain uith the:\c<^any>.                                                                                                                                      w >of f amiliarigation i                                                                                                                                           .. r?, S  S.MS. x  . :tion involved.                                                                                                                                                                                                                                                                                                                                                                                                              in the    -   . ;  \kS ji- r X-A-,1 ;w IJth&r ji^iO@rs;;;bf 9W crev? were C i dti JjKatraS                                                                                                                                                 J                                                                                                                                      ...z >:' : :v *: ?  *    a: .  /.                                                            -.: ::. .. -''  / :.    . /. :' 7f.           .* a/js* .w . /Vr-X.Zb^J ^z. > .^..*  -^i.r-        ,.; *                                                                                                                                                                                                                                                                                                                  : t        EgfrMii                                                                         . Sat?          'ft                                                                                           A ........ tUejtfWs                                                                                                                                                                                     , v S-M-..--, - V' r ^'.VAy^hA w                                                                                           ft                                                                                                                                              r'*?**-*'/  .. 3 k  .Af^         n.,                                                 ' . c^r          \ ~-rr                 . ->:**>  Z   ' 2* A                                                                          Z <                                                                         .X''   .                                                                         %:   v~-X  ' <    \ See our selection of aviatiooijdocuments at RareAviation.com                                                            $Villiam Zspcut, Buff Bay, Portland, Jamaica. Albert Ebanks, 20 Long Mountain Rd., Kingston, Jamaica. Eustace S. Ellington, Lawrence Tavern, St. Andrew, Jamaica Francis Lc-ggc, 11 Holborn Road, Half Way Tree, Jamaica. Merritt N. Cootcs, U. S. Legation, Port au Prince, Haiti. Valter M. Lethbridge, Holquin, Orionto, Cuba. Amos M. Steward, 28 Luke Lane, Kingston, Jamaica.The aircraft, a Sikorsky, Model S-43 flying boat, was owned and operated by the Pan American Airways, Inc., of 135 East 42nd Street, Now York, Nev.' York. It was inspected and approved for certificate by the Department of Commerce on April 21, 1933. and at the time of the accident and pending the actual receipt of the certificate, bore a temporary licensed authorization Number MC-16932. At the time of the accident, this aircraft was being operated oh scheduled ',  ? flight Number 105 from San Juan, Puerto Rico to Kingston, Jamaica with                                                                  inter-. mediate scheduled stops at San Pedro, D. R., Port au Prince, Haiti and                                                                  Santiago, Cuba.On April 22, 1933, this airplane, manned by the crew listed, made                                                         a scheduled flight from Miami, Florida to San Juan, Puerto Rico. It remained in;..9:?- San Juan on the 23rd and-24th in accordance rath schedule. On April 25, 1938 scheduled flight (105) was made between San Juan and Santiago, Cuba, without in- cident. At Santiago, the amount of fuel was checked and found to be 320 gallons# No additional fuel was added. Thirty-four gallons of oil was on board. At the t- time of departure, the gross load of the airplane was 18,238 pounds, The allow- '  able gross load is 19,500 pounds, figuring die fuel consumption, the gross load at the time of the accident was 17,602 pounds or 1,898 pounds below maximum. O Departure from Santiago was made at 19:03 G.C.T. The expected arrivaii> time >- . at Kingston would have been 20:23 G.C.T. The weather was clear with light south*-.;: easterly winds and all reports available at the time indicated favorable flying weather.' All radio contacts were normal throughout the flight and are interpreted as follows:DEPARTURE: - .    NCt-16932 departed Santiago (for Kingston) at 19:04 G.C.T. with 12 passengers (Rodrigues).POSITION REPORT: - AIRPIANE TO SHORE STATIONS:NC-16932 at 19;25 G.'C.T. (Position) latitude 19 20 N., Longitude, 76 00 t?,. flying at 5,000 feet, course 190. Signed Hart.miHER - KINGSTON TO AIRPLANE - .; Surface weather at Kingston at 19r35 G.C.T. Cloudy, visibility unlimited, ceiling 2,000 feet, percentage of overcast 7/10 to 9/10. V5ind S.PL 9 knots '                                                                                                velocity, cloudy, barometer 29.89, temperature 320. Air smooth. Small patch.-; /of blue sky to the ESB. Rain ESE to SE.            ''     ^ITION REPCRT- AIRPLANE TO SHORE STATIONS. '    '-'yNC-16932 at 19:55 G.C.T. (Position) latitude 18o 10, N*. Longitude tVWGV ?                                                                                                                                                                                                                                                                                                   See ourA KPOSITION REPORT - AIRPIANE TO SHORE-S1ATW$^ ..J';    NC-16932 at 20:16 G.C.T.WEATHER - KINGSTON TO NC-16932.     . . -.,. .\3<; , To NC---16932 at 20 : 13 G  C<T> Surface winds' SE6 Kricks ; ; Sea sraoptli.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 a:Signed Crombie, .                                  '           /' '                ..j.,... .....-:       .- :.H>.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    .Ha-                                    -> A*., . . A . POSITION REPORT - AffiPIANE TO KINGSTON. NC-16932 at 20:31 G.C.T.                                                                                                                                                                                                                                                                                                                                                                                                            Pan American to Kingston. Forced down at seairf heavy- swells when left engine quit stop left pontoon smashed but ship will floatjfor some time -with minor leaks in hull stop send boat at once* Signed Hart. -J-             .                          *                                                                             '                                             z                                                                                           .              .  .      -                   _          -..Y ?.:  .   *  . ...   .                                                                                                                                 " -  ;   '?. - ,,                                                                                                                                            ,                                                                           .                                      **.* M >** <   * *   f   % V                         A                .                                                               *.*                           *       *             ' * Z*** **          *. ,V" 4 * * After departing Santiago, nothing unusual was reported until after - Kingston < had been sighted. Altitude, from. 5,000 feet to-2,000 feet had been lost in order . to stay under the clouds as Kingston v/as approached. In conformity wit he om- , .- pany regulations when approaching for a landing, the fuel valves were chMged th i feed both engines from their respective reserve fuel tanks. The- selector valve for the right side was changed first and then the left. Within a few secondsafter changing the left selector valve to supply the left'engine: from the Ihft reserve                                                                                                                                                                                                                        tank, the left engine faltered and quit. The altitude of the airplaneat this time was approximately 1600 feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Ai                  As nearly as can be determined the following procedure Was then follo^ved The left fuel selector valve Was immediately re tiirned to cut in .'the-: mainv-ftihl'tanks but the engine failed to pick up.                                                                                                                                                                                                                                                                                                                                                                                        The needle on the fuel pressure gauge . was resting against its maximum stop vdiich indicated 10 lbs, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              more*-: Normal  fuel pressure is 5 lbs. The nose of the airplane vias                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               pulled up slightly and' 5?of flap was used in an effort to maintain level flight*while                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            While at the- s ame time g . * *:         I       *                                  ,                                 #                                  #                    *         * *              .        9           . .              *. .         .       ***.             .* * *  \                                   %                                       .               *              *.             .               : .     /                                .                                                                                                                                                                                                                                                                                                                        tpth                                          w s  e fe-efforts were made to start the dead engine. The cross-over valve was turned                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              7.:.^. . 1     Z .....     . *         *.*...     ,   .        :          .       s        . . z      .......   ..                    .  .       . .               .        .               ..                                                          .......    .                     \      . -   I*       . Z. .  . .                                                                                                                                                                                                                                                                                                                                                                                                                                                      v   s  ze Epduti in the right fuel                           and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              9                          At                                       v*-ii ,*z ^his tite the .fuel pressure gauge 'readu^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  9                                  arid - tv  - I J,  uWsl'$h&seqtKmtlyhfaked;>t6\1stop;\its<fd^ibh,i'v                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           x*V> C SS5-3 ESlOpRPMTdthamanif old'pressureofappr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           C *  -< -                                              U* plane.. continued to lose altitude at the rate of .a^ftti2:<feet - per-'miiwthr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        z.. v r- V ;c- . .      ........'.:...                                  V                    z"                      - J. v .* .';                                                      /.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     '                              \5> zto y 'f-                            s . J    .             .      .                              V                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ,.ev A**/ \                   .                                                     '     '.        %          "      \.              -       *       . '               '                                                ..............      -         .      .*'    .                     -           t            " .'z                                             ..'.. .. >                                      '                '         r   ; ' Vlien it became apparcnt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      1 fl 9                                                                                                          ft?                                                                           a                                              ?.rz:-4 <".' > r - -<-r z'^-. Sea, - the' purser Was. ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            p.-w<                               -^ZVOX .................      .  .....,.,......... .. ,..^.^......^^0 and a 180 turn; was- exe cuted to :g                                                                                                                                                                                                                                                                                                                                                                                                                             et/:WMt- of th e edge of: Strain'squall                                                                                                                                                                                                                                                                                                            A                                                                *      C * *       '                                       .    ,                    * V*                    .,                                     . Z -V- .-         .      _* z -      ---r-     t      e                                                          Z*   K                 .       -. .    > , - r  The - landing appcarcd normal                  .              .       ? a.   * Z "^ .*< T *  * '   * Z ? \      -            1 *      -  .   .  ?.s.     ...        * B         *                        ..... V ..     z z    >  -1 . z---\ zO----1 - *. X ? . k < - -k                                                                                                     zz^.1<: u                                                                                                                                       $ *             - 'i t                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      . A.. j. z->y Water                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 r?: . <ZI\.. z. -  .z.*u.^< thrown into the air several feet                                                                                                                                                                                               i^jon:thd;; second contact  with . the.                                                                                                                                                                                                                                                                                       p k             v  .. r. r          : -^left-ppntqon '-v^s torn /loose and, the jhu^;<struck-^ . :                                                                                                                                                                 t."  1 .               :.-rW *.?* *                        - .'.  *:'*'?                                                                                :.'. -  . '. ' ...:                                                              ..                _ . . . _/. ..*- ..  /.                                                                                             . s f/ ..*                   './.. ''  '                                               .......- '. ' *' . . -   *..>. ....                                .       ..        .;                            . _       .     .      ..               .z                                                                                                             * .      . .                   f.....!                                                                                                            ' ;                                                                                                                                                                                                                                                                                                                                                                                           y 1 An inspe ction of :Wo.-aif?plane/ toEdetbsWiihe-'O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       M5Sft*W;                                                                               >?'h<^pzsU^aixied,-- it.'iWrsRfbund^the hull l?---ihe:ipilbtMbti'the''.'Mrbi^dSWSii *                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      **>v                      - .^u-^b->=\-  .v*. - -a- x.?.J-;- ?<-. ..X11-                 ;                    \        '  <;               ' ?c::                  ..< >     < z.''         -ia. .. r.;-:           : -7  :. .; ::z;*  ; --:.: .:7- :/.       ;                     :                              .   - ...  r        : ?  -z.^:.                         .X-                                                                                                                                                                                                                                                                                                                                                                                                      \ <i.       -.< tract the steamer SS Cavina                                                                                                                                                                                                                                                                 e                                                                                                                                                                                             A                                                                                                                                                                                                                                   ifl, ife                                                                                 wl cz Jl-A                                                                                           c-'-v- for ppSJSibll Clufgcncy                                                                                                                                                                                                                                                                                                                                                                 ri *1: . ' wry : :  .y .                                                           - ^ . . x -x-.-  -. ...  _ . A.Z... . x. "Z.  zz  V .  CA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             5                                                                                                                                                                aT-kJV ?^s                                                                                                                                                                                                                                                                                                                                                                                                  *r                                                                                                                                                                                                                                                                                                  >>r;V^:YV; \ =: They then proceeded to the steamer in the rubber life raft. From the log of . the steamship SS Cavina,'the airplane was sighted; disabled at 20:21 G.C.T. and fisank at 21:45 G.C.T. A launch and a rescue tug had been dispatched to the scene from Kingston but arrived just after the airplane sank. However, three ;./ native canoes in charge of a company employee did arrive at the scene in time to have effected a rescue.                                                       ' .'M: In reviewing the facts and circumstances surrounding this accident, nothing unusual was revealed in: the dispatching of this airplane cut of Santiago; favorable weather was predicted and obtained. The rain squall encountered after sighting- Kingston could not be considered serious and vrauld not have constituted a hazard to the flight had both engines continued to function. The three main '/ points of consideration seem to be:                      "   1.  The reason for the failure of the left .engine. 2.  The inability of the airplane to maintain level flight while operat- ing on a single engine. 3.  The reason for the airplane sinking.                  ', .From available evidence, it appears that the engine stoppage was the re- sult. of a failure of the fuel supply system. Several possibilities for this failure were "considered, including; an air lock, failure "of the valve mechanism in the fuel system, and foreign matter in the system. The latter appears to coincide with the weight of the evidence available and is outlined as follows:When the selector valve was sliifted to the reserve tank on the left side, a surge occurred which dislodged or changed the position of the foreign parti- i cles in the system. This foreign "natter caused a stoppage in the by-pass in the engine driven fuel pump. V'ith this by-pass closed, the fuel pressure in- creased to more than 10 pounds. The increase in pressure caused an abnormal amount of fuel to pass the carburetor jets which in turn caused the motor to fail due to an extremely rich mixture. This abnormal pressure, which may have been as high as 20 or 30 pounds, may have caused the copper fuel line between the pump and carburetor to pull away from one of the two rubber hose connec- tions in that line. The points brought out in the testimony 'which seemed to bear this supposition out are as follows:(a) The failure of the engine occurred almost iimifediately after the se- lector valve" -was changed, which indicates that the change of the selector valve did not result in loss of fuel to the carburetor, inasmuch as the engine would have run 20 or 30 seconds on fuel in the carburetor and the lines after the fuel had been cut off at the valve. Ch the other hand, the change of the valve could cause a surge in the line which could dislodge or change the position of any; foreign matter in the pump or line.(b) The fuel pressure gauge indicated a pressure of.more than 10 pounds by reason of the fact that the hand was against the stop on the high pressure side. Had there been a lack of fuel in the system, it is not believed that this excessive pressure would have been indicated, whereas-, with the by-pass of the pump blocked, an excessive fuel pressure would be a natural result.(c) From the testimony of the pilots, the engine stopped without back- dr giving other indications' of a lean mixture or lack of /fuel. The the engine stopped appears to indicate an over-rich mixture*  ;y                                                                                                                                                                                                                                                                                                                                                                                 > -S'z<^>rV>* ."' XW1                            A                                                              v>            :. Av f- ?r< <>(d) . The fact that the pressure gauge1 show                                                                                                                                                                                                                      V- > I.,fdr a certain length of time."and- theft droppod to zero soems to bear out the supposition that the fuel line carried away have shown that fuel lines similar toZ ,t^.Zohbz':iiiz.<i^^ pressures of 30 pounds or more when oil is presont in the ccnnections betFsenZa, the copper tubing and the hose or when the clamps or line beads are not in . perfect condition. Such conditions might occur in an installation which ha been in service for 350 hours, as was the case in question. . a /ZZ//:<Z.Z/ZZyaJNo evidence could be obtained which would explain why the airplane didZZ not maintain level flight v.dth one engine inoperative                                                                                                                                                                                                                                                                           'Previous to the approv ing of the airplane in question                                                                                                                                                                                                                                                         iirplanc of the exact type was tested for y single engine performance under full load condition of 19,500 pounds gross an                                                                                                                                                                                                                                                                                    successfully maintained a density altitude of 5,700 foot. At the .time of those tests the operating engine was developing 695 H.P. Viicn the left engine fails on the approach to Kingston, evidence indicates that the airplane was. flying at a density altitude of 2700 feet, and the operating engine vas. computed to bedeveloping approximately 750 H.P. The gross weight at this time was estimated to be approximately 17,602 pounds. All of these conditions were more favorable to single engine flight than the conditions which obtained during the tests                                                                                                                                                                                                                                                                                                1 described above * There are a number of factors which may have made single                                                                                                                                                                                                                                                                                                                                       M/ i engine flight difficult in this instance, as follows:                                                                                                                                                                                                                                                                                                                                                            . z. v* n '4 I > . > *z1                                              The pilot had insufficient time to trim the airplane for the most favorable single engine performance due to the complications in-                                                                                                                                                             I volved in attempting to start the dead engine, avoid the stormand prepare for an emergency landing. 2                                              The left engine on failing, would cause the propeller to auto- matically go into lor; pitch which would tend to lower single performance.                                 yp ;-.                                                                                                                                                                     : . The water vapor confent in the air was./hi^h-:-thicb. would                                                                                                                                                                                                        &ytdh|^b<horsGpo^^                                   ':f:,ft...'            :-feg                                                                                                                                                                       V '< Z; 4.4 The rain v-ould &creasp:'\;tihe:- amount of  horsepower necessary: v WfZ;                                                                                                                                                                                                                                         L z i': flight. : '. Z- : Zify <' ;Z. yZy-f; ' z' Z< ;.Z f : 4-Zy;Z Zy: . y: Zyty g ;.Z'y :'f f< Sy                                                                                                                                                                               zV--^r,^ -zz. C. z ..% z 5.  Pilot found ;ltZhecesSaf^        left to get'-                                                                                                                                                                                                                          *              >> - I   zZyyZ w^ch^placed the dead engine &a  the. :low;';sl^Zb^ ^b:Zt^n*yy f  ii                                                                                                                                                                                                               / V 15 -U v      .'.>AV s*- 4.       > .,!/ -4-^ J. \ - A  -z- WaL** *   6. Airplane                    rough air at yti&ebz                                                                                                                                                                                                                                       * *-       <-> .  v^z-A iu ;y?^yZ:y^^?;pf the squall.-Z* ZZ-' Z^Z.' ZZ.JZ_; wZaZZyyyy/Zy:--yt '<zZ<yy;yg:a                                                                                                                                                                                                             r  'v-'- " t. '.SZyy a In /arriving at  conclusiGns as to Wiy the airplinc sank, pp-..Gyid0hpbS^                                                                                                                                                                                                                                                                                                                       .smL zTi cxactcxtcntofdamgcinrai^                     .....                                                                                                                                          ^:Xr^ "x- >x rvzy:> .-X ^tibn raade by the; pilot                                                                                                                                                                                                                  Hl                                                                                                                                *v. plane would remain af Ip a t until; as bhBzag c                                                                                                                                                                                                                                                     A                  '&c^.;KihgAtbi^-:5Z^                                 &X" *r chieff concern at the moment was theysafcty; n f^jii^apassdhgQrs andtxnbi-L Iblaqsr vjoro /safely, on board the s teamer                                                                                                                                                                                                                                                                                                                                              yTywy: :t^bbi?Z<AtZn^ d^cr:: evidence, it /hppphrs.? tlxat; the;rap|d increase' in theafate of /:.tpki^Zpn ..atefyfapZ^'-' to the nWiOe'at tOBypi ap|f^iahcZb^'nb^Z'M'-:Jtjbt,4withZihb/^                                                                                                                                                                                                                                                                                                                                                    ' /I W -> -   z---  vw*% * part1 -bia/thea/aif                                                                                                                                                                                                                                                                                                                  A                                                    " ' z>      -Zi* Zbc^Zii.cniZ0f<than:.'thc.;ievbl:-ipfithc^Z                       ;aii^3^bZ<SG/tf^d:lS^^^                                                                                                                                                                                                                                                                                                 a vS:4 ZZ;ay Z11 ZZy/Zy? y gy/Zyt gz                                                                            i: >lafc-'.:to;sbinh  sooner , ti                                                                                                                                                                                                                                                                                                                              *L          f           -Vvx 't:r  A'::                                                                                                                                                                                                                                                                                                                        X       CK-'A>i-A .....    .  --- 6 --- .                     See our selection of aviatioon documents at RareAviation.com -/arriving at a conclusion, after an analysis of the evidence available, it does not appear that this-accident v/as due to any failure of the company or cro^T to' operate or navigate the aircraft in accordance with prevailing rules :ar^5jtt-acticos< Vfhy the airplane did not maintain altitude with one engine in- ojfcrative is a matter of concern as previous tests indicate that airplanes ok thi^ exact type should sustain a reasonable altitude with one of the two engines stopped* . The sudden increase of taking on water and subsequent sinking of the : airplane before the arrival of the salvage tug is likewise a matter of concern^. ' The depth of the rater in which the airplane sank precludes the possibility of raising it. Wore the airplane available for inspection, it would no doubt be possible to determine more definitely the answers to the three main points under consideration.                                                                          .  ^Opinion:        1      '                           '                                           felt is the opinion of the Investigating Board that the probable cause of thisjaccidont was failure of the left engine as a result of a failure in the fuel system and failure of the airplane tomaintain single engine flight.G. C. MILLER. (Chairman) Asst. Chief, Airline InspectionSection (Foreign) D. MURPH! Approved and Forwarded;-:                        Senior Airline Inspector E. J. GREER            . ;feDENIS Ip/LLIGAN / Director, >                                      Airline Inspector (Foreign) t Approved and Forwarded:                          Appr o ved: J. M/JDHNSQN                                     DANIEL C. ROPER ... Assistant Secretary of Commerce                  Secretary of Commerce rAA-                 =:y saw Al R SAFETI. BCn :  v of the CI VII           AEWAUTIC                                   T-ORITT/?zV-rPREI.IKINA Rf WORT.OF THE DISAFPIL:RANCE OF                                                                         1IRCR.FT OF AN vyFRTCi?!                              WAYS,                                                      CCRPORM'ED,. N THE             VICINITY OF I                                                                               12 27' NORTH                    LONGITUDE 1.30" 40 EA.                                                                                                                                                                    7:: ON JUIY 29, 1933. -A i- In an order dated August                   17, 1938, issued by th                                       o Secrota                                                     0.1. - be!uro pursuant to the provisions of                   the Air Commo roe ^ct                                        of 1926,                                                      z-tchad'C:t                                                          r .7:>>A<S.;tr=viR. D. royt, /aeronautical Inspector, Phil C. Salzman,                                                                                                                                                                                                                 .                           r * . <inspector, and A, t. Miller, Airways Superintendent,                                                                                                                                                                 Intcrria-tional Socti.ote were designated as a Board to Investigate the facts,                                                                                                                                                                 c orditri     and / :ct cumstances surrounding the disappearance of the Hawaii                                                                                                                                                                  Clinp^r, pti airc:ri-t; of Pan ^merican Airways, Incorporated- while flvine we                                                                                                                                                                 stbovnd between Gudiil and Manila, P. I., on July 28,                                                                                                                                       and to make a report thereon. Dolonol Sumpter Smith and Mr. Thomas 0                                                                                                                        Hardin of .shingtcn, D. C., were dcsig- nated as -'/' r/d-! rt, Board convened at Alameda, California,                                                                                                                                                         oil August IS, l@,ah promptly                                      instituted an investigation After a                                                                                                                                                           reliminary survey, th fried it inadvisable to hold a public hearing ar                                                                                                                                                               that ti-ino ;md                                                                    -  s--,.-:w:-. .:. -T ~1! 'A ..  *.*---<-*.- r- -3 report to that effect was made to the Secretary of CommThereupon the Secretary of Cpmmerce directed that                                                                                                                                                                                                         Board be re-lieved of that duty, and directed that it continue the                                                                                                                                                                                                    s tigati on arid                                                                                              *iz;> delive r   its rep                                                                                        u oi seen invtswg'iwwi w-vuc /i-ll- safety Rd-urd of the                                                                                                                                                                               */-*   w .  '-J uthoritv, as ioart: of the records of the ;bepnrtmtnt-;;cf <                                                                                                                                                                             .J.        w- Civil Aeronautics                                                                                                                                                                                                                                                                                                  ; r :>j Commerce transferred t                                                                                                    the Civil Aeronautics authority pursuant to Exdcu                                                                                                                                        . . ; -?,             . i'-- tive Order 7959                                                                    dated ;ugust '22,- 1938* hi .j.                                                                                                                                                                                                rz  .  y.svz -tt; r-u  -?: C.: Th Board                                                                                                                                                                                                                                                                                                        Bsa follows: *  -.V A*, ss .;T% -        7L On July 29                                                                                                  , at 0411, ;:Greohwich;-;Civil; Timt                                                                        the' Captain; ofAthb                                                                    :7 i:Hawaii Clipper,                                                                                             re ref t of Pan . ...merienn - Airways,                                                                 Incprpo rot ed, flying                                                                        r-<7. -  westbound between Guam and                                                                                                                       nil?., r. I., in regu                                               scheduled; f oraign yf:.;# air commerce, sent a rout in                                                                                                                     radio- position ropor                                giving ; thc-i r 0/..00 OiiW? position as being Latitude 12"27                                                                                                                                                                       North. longitude: 130u40                           Ens t. T'i s                                             ; _   / ' a. _ . - *\2-*- -zS-s sition is appx'OxiirJteiy 582 nautical                                                                                                                                                                            es east southeast The position report -was received by the- radio operator at Pansy who was nt -that - tim^ standing radio guard ever the oporoti on                                                                                                                                                                                                   rauay knowledged this;' rtpoitAand reqboste'd: the. Clipper to --s*                                                                                                                                                          equosroa Uiie viippsr so spanc; try; for -. rortiro weather sequence report                                                                                                      The rodio opaiiitor on the Clipper reauosfed t the. re.popt be held up for a rainute on account of- roin                                                                                                                                                            ;' static. Folldol that '.:..i^i^eht,;'t                      htlianay-was-; unable- -                                                                                                                                                  t c ob tain. acfeWl^^SK                                                                        ^z. *   us  "T. -ement cf messages sant the Clipper,; and si nee th.'-1 <h t                                                                                                                                                           e no reason rhl  x : J ~                                                                                             *z -  -         r---zr -      nationforitsdisappaarancGhcishGenfcund.                                                                                                                                                                                                                                                                                                     ^X         r-y-c-;-yi Th... date- and time-iaAntiohed                                                                                                                  ibove corresporid to 12:11                                                                                  hi;;                                                                   x   *z * ** J      - k r . Local Tim; at ^ahil                                                                                                                   and 11:11 F W;Time; Wi -tA > J ^ 7! ' '    >-w\z.V-K V  GW1 RareA vi i 0M  V: 3 r :>* .;' i                                                                                                                                                                                                                                                                                            };*J -O:- From  PilotManua                                                                                                                                                                                                                                                                                                                                                          *>'2' Z4 << ,*.y *5 '     4 ,     } <          1 <.X .                    * *  *  .                                                                                                                        r-                 83 \ ' **'  V *  >*w   ?                          | 1 .vit*                                                                     /                             V'           ;.x ..??%' kY. * >                                                                                                                                                     A   < * *.Vv s                * ? T* * (   *   *                                                             .                 r     \.                                                                                      i                                                                                           .  N) 1>t the time of the aircrafts disappearance.                                                                                                      y--: vuv: uidiu ox bne?aircrit 's disappearance, it was b<:-5'ng ,       flO'.'!       in ; scheduled foreign air bommeree under a letter of Authority dated                                       ptembe 19, 1936, .'and carried passengers, nail and express.                                                                                                                                                                                                                  The crew consisted the Captain, First Officer, Second Officer, Third Office.                                                                                                                                         r, fourth Officer* &igineer Officer, Assistant Engineer Officer, Radio Officer and Fli~ht~The Crlp^':?n Leo -Thrletsky, hold ?. cv-rent and epprepri -te Federal ' r.         Certificate of Competency, and th: required ratings for th. flis-ht involved. His last physical examination as required by theDepartment of a- . Commerce was taken on April 20, 1938, with a subsequent physical oxreiin-ticn^ ,jS.. taken on July 21, 1938, in ccnfomity with Company regulations for all fl<eh^l personnel, both of which showed him to be in satisfnctoiy physical condition^?' . Captain Terletzkys record indicates that he had a total of 9,200 hours experience, Of whic11 1626 hours had been in trans-Rici tic cp<ration His total flying experience in the Martin, Model 130 Flying Boat, was 161 z Wl hours. His total flying time in the preceding year was 826 hours and hia---lW .,a flying time m the month preceding the start of the Subject trip was 6 hours^  ^irnt ?f^Cer        ,rnlkor hald a current and appropriate Federal & Pilot s Certificate of Competency, and the required ratings for the involved. His last physical examination as required by the (w^rtmonVoW-W Commerce was taken on February 28, 1938, with a subsequent physical .xnminaUWi ;..tin taken cn July: 21, 1938, in confon-ity with Company regulations for al.<W (.- p^rscnnol, both cf which showed dim to be in satisfactory physical- condition* His record showed that he had a total of over 1900 hours flv&i 1575 hours of which had bc-en in. trcns-Pacific operation' ' mi +?Cnndx^1Cer Gecrge Qlvis held a current and appropriate Federal 0f?0!^tcy (License), and th. required ratings for-                                                                                                                                                    - flight involved. His last physic.-.! examination as required by the De--- partaent of Commerce was taken on February 14, I038, with-a subsequent'    ^CnVX^TSn. ?ke C'n Jly 21 193^ in confomity wi th Company' . lotions for all flignt personnel, both of win. ch showed him to bo in saUi21 5              ?cndltln- Pilot Davis- record sho^d that he bad a - pf hcurs n^ng experience, 1080 hours cf which had been in trans-, -.g-racific operation.                                                              ..fi^cer Jose.'M< Ssuccdm held n . current and r.poropriate Federal S                of.Ccmpeten^ (License), and the required- ratings fet'p1fe01Ve<4 lQS 1>5t           ^-^-ainition as required by tle partaent of Comerce was taken on Janun-ry 7, 1938, with a subsequent physO?^ fortSken n JUly           ln ccn-Por,!lity '^th Company regiilftti^i^ for all flight personnel, both of which showed him to be in satisfaciz'ra--^ Physical ccndj.tion. His record shewed that he had total of 1900 hoiiW^^ experience, 570 hours of which had been in trans-Pacific operation feW                                                                                              John  jCT?ett 3ield a current and appropriate Federal A:f;f ComP- tt;nc^ and the. required ratings'for the fligliffe                                                                                                                                                                                                                                                              i- ^volved. His last physical examination-;           '                                                                                                                                                                                                                  s required by the Department^jM^^W^takeii.'cn June- 23, 1938, with                                                                                                                                                                                                                  . .. _g subsequent physical  ^xaciinatij^ July 21, 1938.'                                 , i tn.ccn -^orpli ty ?'i6h, Company;: regulations fq r all fl .- b21 -              ' hia S^rSrisfacte^y "physiol                                                                                                                                                              conMS -,  z zii j , ..;,.%. z %  F *zif-:  j  k  , .  ' /                         -"T.lt.' 5)            '' ' <<1  ,' :'                               ?> <. A - X  2'      v ' :' ? : to 1& -< r.y: , v. r . of wi.cu.rrc-.r.o' Of : CcWO ..a taken on July 21                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 ggS /                                  '{fir ?.ll flight pursorncl^ y.-c                                                                                                                                                                                                                                                                                                            a ti s i n c to r-r. phys                                                                                                                                                               ,.\ s. ;. 1 Ct vliMmW record showed that he had over 944 hours                                                                                                                                                                                                                                                                                                yihg. experience fic                                         operation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                X v'J ws Ws5 4 sis tan t                                                                                                                                                                                                                                                                        hgineer Officer T. Tatum held, a current                                                                                                                            i.yyxe                                               L. -U- r'.z/S Z - O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               - " >< - Fede ral     Ai rc ra.f t                                                                                                                                                                                                                                                                      lecnanic's Certificate of Cenpetericv. he                                                                                                                          3 the                                                               2 airc raf     t at Honolulu and was on a trainHa die Of fl cer "Wil liam Me Ca rty held                                                                                                                                                                                                                                                                                      a federal Ffedio ricon                                                                                                                                                                i-.rtvt                                                                                        .Z- * <\ Class His last physical examination,                                                                                                                                                                                                                                                                                          taken on July 21,                                                                                                                                                                     confCi:^!^                                                                             w pe.vsotme! , ohcv-ied                                                                                                                                                                 .       '       . -xz z                                                              C"> *7^ with Company regulations for all flight                                                                                                                                                                                                                                                                                                                                                                                                                      hiin to :ba:lpj-:Wg;                                                                                                                            ^Ss5: satisfactory physical condition. His 'rccoi-d showdi                                                                                                                                                                                                                                                                                                                                                                                                         O'            litnfiS radio experience in ti*ans-Paci.fic operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  :/ The 1 light Steward was Ivan Parker. Ins last                                                       rhy s i cal exaM - a to                                                                                                                                                 r  :X taken on July -21, 193c, in .conformity .with Company                                                       rogulatiens for personnel, showed him to be in satisfactory prysto                                                       1 corvditio shewed that, he had 1200 hours flying lxperi-ence in                                                       tra                                                                                                                                         ope x-atioW'                        ^.r^SSvThe passengers were rd E. ^yinanp. 1                                                                                                                                                                                                                                   ronxv.i                                            r- Yoxic                                                                                                                                                               ---M-.' ' J 1                                                       ll f o rni ?. t. Kennedy, 25?z                                                                                                    OVD 1                                                                                                                                                                            - (: Earl                                                                                                                                                                                                                                                                               x*rO'C *                                                                                                                                                                                     tss^ - -  : cl s zA-4 5-* - z< Xs Fred G.                                                                                                                                                                                                                                                                                                                                                                                 kJ ; - si V Borflan Ha jo r Hovvt: rd Fren cl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              '  '.' .Y ' '' ->;; J*Ss s--4Choy Suh< < 292$ JWW                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       :: * .'-.J3The aarersi t,;.:*                                                                                                                                                                                                                                4c deli-130 fly                                                                                                                                                                                                                                                                                                                                                .;. ? kyithef Ban Aneri can Ai rwayc                                                                                                                                                                                                                        [heorpbrsted,                                                                                                          o-se prince :        v York bit -, <.                                                                                                         ' I t WC:fl$ll yc is 135- Sat *                                                                                                                           1 Ur::, J'  /  .                                                                                                                                                tomif actor operate r t                                                                                                                                                                                                                      SiB-^brth^on- y leafod                                                                                                                                                                                                                                                                                                         > -7.- t' i>'/ *<'**-i. and was last cert                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  -A -. .2;< t; ??'- Corti fieaid                                                                                                                                  otoAWwrtW*                                                                                                                                                                                                                                                                                                                                                                                         2   - aff yJ' Ori fopUmbc r 19,. 1                                                                                                                                                                                                          1X1:  Lfepr-                                                                                                                      Corjuorc carrl^ the,, operator to, utilise                                                                                                                                                                                             co between                                                                                                                  ,.;C               lifcxnn                                                                                                                   -'y to cargo, to . schetol-^'                                                                                                                                                                                                 at Honolulu                                                                                                  ? ;-l&W< ; ti th inti. T?iu d i ?s.t c. st to                                                                                                                                                                                                             5ie                                                                                       rd con di ti one iu.clu-:.: g to ; toitolpto<52 G^')toO1 ?ls                                                                                                                                                                                                                                                                                                        suf ficlonk fw.l to rvwce ptototo on          j-tti son. jJig                                                                                                                                                                                                                                                                                                                                                                                                                                          .:. c.-M=&cifie sextos liforrto,' a-.dj   > aircraftltto^totto    jfrond tripcue rfxtohr'.-tpto-oarturAi?xe hours whan.last repor                                                                                                                                                                                                                                                        *   .    V...    .                                       .                                  % *- . . .          z            . .      ..          .                                              >                                     z         %     *        .,   *.                      w .. - .      'J/;'.." ':...:*                                                                                              : i I \v 4 - l y.*^-'.: ;v.?<                                                                                                                                                                              hov rc, |had' <vC*.'                                                                                                     B                                                                                                                                                                                                                                                                                                                            ---'From  PilotMan                                                                                                                                                                                                                                                                            *>.:: - -x. .%. - _ > 'j .fcrj. -             '' *   <- ,  . .tL,  J: ' , J*<:    : ^ ' iOW---* 4 ---1.           Left outboard engine                        3:43      hou rs 2.           Left inboard engine                       137:26      hours 3.           Right nboard engine                         3:4B      hours 4.           Right cvtboird sngine                     293:25      hoursThe propellers, which are overhauled at the same periods as the                                                                                .;ngine?|5g had the following hours of service, after overhaul                                                      at the beginning of ?rip No.. 229:1* Left outboard proptll;r                             140:41 hours 2..- Left inboard propeller                                140:41 hours 3.  flight inboard propeller                                 3:48 hours 4.  Right outboard propeller                               140:41 hours The operation and maintenance history of this ai rcraff has b                                                                    norm! in all respects in comparison with other flying boats operated by the Pan American Airways Company between San Francisco and                                                    Man 11All changes rccommeded by the Glenn L. Bartin                                                        Company had bean                                            tsd on the Hawaii Clipper and thore 75 re no incomplete                                                  overhaul items carried? over to the hext arrival rt Alameda.The trip in question                                                       was known ?s Trip ho. 229, scheduled from Ale mods, California, to Manila, F.                                                  I. Departure from Alameda was made on July 1938, the flight arriving at Horolvl:                                                          on July 24th. On July 25th th:?                                                 trip ere July             26 th was continued from Lon.lulu to Midway on schedule, arriving there July A scheduled.departure was made from !<?dway on July 26th and the flight at Wake on July 27th.  It departed from akc on July 27th and arrived nt \;at 0555 G.C.T. on July 23th. Departure from Guam was made at 1938 G.C.f* (3:39 A.M. Manila Time) on July, 28, 1938, th? aircraft actually leaving the water 2?-minutes later. Sunset at Manila, the destination, was at 6:29 p Manila ./line, thus giving 14 hours and 50 minutes of daylight for the  The fli-.ht time analysis indicated that in standard cruising at . altitude'of 7800 foot, the flight would take 12 heirs 36 minutes                                                                                                The re  2550 gallons of gasoline on boards and 120 gallons of oil. This                                                      and 120 gallons of oil. IMs amount of gasoline was calculated to provide                                                                       a cruising endurance of 17 hours and 30minutes at cruising R. r. M. under the                                              conditions. stated above. The carried six passengers, 1138 pounds of cargo, and was lorded to r. gross / ./<weight of 49,894 pounds at the time of takeoff.              .     * *   * *  At 0330 G.C.T., 41 minutes before the last radio contact, there aboard the aircraft 1420 gallons of gasoline which is sufficient for 10.1  ; hours of normal cruising. Ibis would indic-'tc that there ^.s ampla fuel aboard to raach kanila and continue the flight for severe! hours tl'-axx.nftsr< ::;The records show that- the trip fr?'m Alameda to Guam vnS unvvcrtful..5 /i '/leather conditions were better than average, and each leg of the trip.wasi : ^accomplished'on schedule. Between l-adway and Jake, the ecu rsj 'followed Ms /^considerably to the South of the regular route due to bad:-wither nlop^tfeS; //route and to the north. This procrdire is ncraal, as regular a] toraatc rout are laid oi?t for each leg of the Pacific operation. The route          ft>rj /?tany trip is based on vrehther forecasts made prior to -departure, . and ,ntny bo changed enroute at the discretion of the Ca.ptair , . . .         '    . ... -.sxpr           4re-;ttes;-The records alsoshe                                                                                                                                                                                                                                                                                                                         ordinary routmo radio                        c onrect: maintained between, the aircraft and the                                                                                                                                                                                                                                                                                                               hor stations on                   guard or                                                 .-.ch log                            <* of the trip. Company procedure require                                                                                                                                                                                                                                                                                                                that a constant                   guard b< by radio stations at the point of departure and destination                                                                                                                                                                                                                                                                                                                                       all times while the aircraft is in flight.Prior to departure froi                                                                                                                                               Alapiada,- the aircraft was -inspected,"and service procedure, known as                                                                                                                                                                                                "long airplane survi.ee" and "long engte; survic as carried out. The "shor                                                                                                                                                                                                                            run up report and eng nocring flight tests showed satisfactory operation                                                                                                                                                                                                                                                                            Die Companys routine procedure calls foi                                                                                                                           i .fVvW* test flight                                                                                                            of at least tlirse hours'on the day pr- ceding departure - WW moda. This                                                                                                             flight is conducted by the same crevr scheduled to make ,.th<$#44$                                                                                                                                                                                                                                                                         !.< -,v_<During              this flight an emergency landing is made ano a roi                                                                                                                                                                                                                                                                      'iln rdon ship drill              is carried out. Ttes drill consists of inflating t and getting              it ovir-stee, with the crew, .w.rgency eouipmait :>.r                                                                                                                                                                                                                               nt during emergency redio is set up and cowunic tic/-                                                                                                                                                                                                                                                                                                           aboard. An                                                                                                                                                                                                                                                                                                                                                                         ?;i-7 A'.SZ established. All members of the crew have n def ini t s maneuver.t Honolulv, Midway, teke and Guam th. Daring over-night stops was serviced and inspected in                                                                                                                                                                                                                                                                accordance with rcutin6 proc-..-dure which. osiW^for "over-night airplan                                                                                                                                                                                               rva.ee and evor-riight chgir& co rad co " . .former requires inspection o                                                                                                                                                                                                                         e'vital parts and the addition of-.fuel water and auxiliary fluids,                                                                                                                                                                                                                           The latter reouires a .detailed testecacn oreWgj and ?Bstallat5.ons.  o signlfleant i rrteul t t"- felfe engines, and thesr controls                                                                                                                                                                                                                           teri.neer or detected by the resyectiv? < airportwere reported by the Flight                                                                                                                                                                                                                                                                                                                                                                                                                                                 jy<Av r; Chief Mechanics.                                                                                                                                                                                                                                                                                                                                                                                                                                                            t^T i < r- -v<- a- Clipper.met ;the; fhiiiPi^e; Clipper At Wake Island, the Hawaii eastbound, both aircraft making                                                                                                                                                                                                                                                                          a scheduled .overnight stopTestimony from members- of the crew of                                                                                                                                                                                                                                                                                                      hp- .PhilfpP^f- 5Uppeh,'ibdi^at^j.^^fe5i& the entire crew of the Hawaii Clipper                                                                                                                                                                                                                                                                                                       g3?q intepbrte4fa/ccfprteble and ho rani trip r.p to -. ..  '-p ihe trip weather forecast, prepared at 1322 0.                                      ns f ollcrcsdifch the 'aircraft. - was di spatchod - from Guasi, . wa. Zone 1                                                                                                                                                 Zone 2                       : Zone 3? ire                                                                         3-W^W , , o ,                                                                                                                                              ,w  !                       Long -130  to                                                               ... A'-," .-, *--*:.- >' Long 145 >                                                                                                                                           Long 140                       1/0 EtStM-; 14dlfcst .                                                                                                                                                                                                                                                                      ---'x -SC* Weather condi ti                                                                                                                                                                   ons     Scattered <                                                                                                                            Scattered                                    . showers                                                              ..... :,1 ',\CTr'-.4^X< shoxrers                                                                                                                                               showers                      Good yiMbili.ty                                                                                                                                    Good                                                                                                                                   Good . 2,500 ft. .                                                                                                                            2,500 ft.                                    l^GOd;. ft                                       -y.-v -"! ; >' -': <- 8.000 ft.                                                                                                                             8.000 ft.                                                                                     .; : '; -:' i < idipis * :< >.;>'.       ;> .<1 /ffj 31 i ght                                   SiigiOS                             r-* >: ''f- S^iConctetJ-OdS:-.; .-/                                                                                                                      Slight                                                                                                                                                                                                                                              f > rX zy 4 OS aS                                                                                                                                  -8 - C-S AS                                                                                                Sr:^- 'BaOibf        y-'.i.-:                                                                                                                                                                                                                                                                                                                                                                           r<^yS-,-: ii^ood w                                                                                                                                 14,0:                                                                                                     z?Z< teh w i'Gl oud 8:   1; i A                                                                                                                                                                                                                                                                                                                                                         -t ** '*'{ ' T.V.*X^VX                                         ;<T\\ %>-> *:*. f                                  *<.-                                                                                                                                                                                                              :x *'- <> *. ' *.*..                                  WSB  i                                                                             ?-A*, f  >rx! . .  z/ . .       -         z      .                                    *   z  '  ?; :   ''*<' *': *.x ?//<' x<                                                                                                                                                                                                                           .10 feet.                                       1 Jv \n -- * if-.-. v>                  re ' ^r.- '  -/.^x.                                                                                                                                                                                                                                                                                                     * -*-' <.. *. 'C-.:                  > ..'i'JP*': ?fz- > 5;;rL <j: YC.;; :  *< *> - 6The foregoing         forecast was issued by the Company Meteorologist, whose headquarters is in         Manila                     F. I;Local weather                                                                                                at Guam                    at 1939 G.C.T., the time of departure from that point, was as follows: lea the r                 Conditions                                                                         -rartly Cloudy Visibility                                                                                                    -Unlimited Amount of Clouds                                                                                              -2/10 - lower 5/10 total Height of lower clouds-2,000 feet leather for past hour                                                                                         -partly Cloudy Wind                                                                                                          -WSF 6 Barometer                                                                                                     -29.83 ^temperature                                                                                                  -8G F Vater condi tions                                                                                             -Moderate The local weather at Cavite, P                                                                                                                    T                                   at this time, was as follows:ea the r Con di ti ens                                                                                        -Partly Clovdy Visibility                                                                                                    -UnlimitedAmount of Clouds                                                                                              -1/10 Height of lower clouds-.500 feet eather for past hour -Partly Cloudv nnd                                                                                                             cr 4 Barometer                                                                                                       2o. ?6 Tempe ratu re water Conditions                                                                                              -SmoothGuam upper air at 1830 G,C.T                                                                                                                                                                                                                Cavite upper air at 1700 GOT was as follows:                                                                                                                                                                                                                             was as follows Surface                                                                                                 - W 6                                                                                                                                        Surface                     - SW     3 1,000              ft. - w           10 1,000 ft.                                                                                               - W 10 2,000 ft.                                                                                               - W14                                                                                                                                        2, OOO             ft, - w           16 3,000 ft.                                                                                                  - WSV< 1?                                                                                                                                 3,000              ft- w             16 ' 4,000 ft.                                                                                             - W18                                                                                                                                        4,000              ft. -w            15 5,000ft.                                                                                                - T?SL 19                                                                                                                                    5,000              ft.        VJSW 21 6,000              ft.        V 11 - 6,000 ft.                                                                                             - W 21 - 7,COO ft.                                                                                            .         18                                                                                                                                 7, 000             ft.        'it 12 8,000 ft.                                                                                               - uS. 19                                                                                                                                    8,000              ft.        "ST 20 /. 10,000 ft.                                                                                             - TiSW 17                                                                                                                                 9,000              ft.             12Radio                                                                                                      facilitie    sat Guam consist                                                                       of a Company Station KMBG. Other sta-T tions standing guard on the operation                                                                                                                                                                   between Guam and Manila were Par.ay :  KZDI and Manila KZBQ. In addition.                                                                                                                                                  other Pan American Airways radio stations in the Philippine Islands were                                                                                                                                standing watch. Ihe aircraft was equipped with ; two ir-depaident transmitters,                                                                                                                                   either of which could be used for co.minunicating on assigned frequencies or or the international distress frequency of 500 kilocycles. Radio communication was maintained in a normal manner up to 0411 G.C.T. At that time a routine report was sent by the Clipper giving .. th$?ir position at 0400 G.C.T. (12 Koon Manila Time)..Tire message was as follows (all communications are in code and messages .quoted a-rc                                                                                              interpretations): -kt /-;'   -' -r-v- <'"Flying in rough                                                               air at                                    9100 feet                                                                                                                                     il13^ centigrade.                                                                 Tnd 19 knots per hour from                                                                                                                      :a -/ J: 247^. Position Latitude 1227* N. Longitude130 40* E dead reckoning. Ground speed made good 112 knots. Desired track 282. Bin. During past hour cloud conditions have varied. lO/lOths of sky above covered by strato cumulus                                                                                                                                                                                                                     1. cloudsj base 9200 feet. Clouds below, 10/lOths of sky covered by cumulus clouds whose tops war 9200 feet. 5Aoths of the hour on instruments. Last direction finder bearing from' Manila                                                                                                            101                                                                                                        ya True."                                                                                                                                                                                                                                                     id.rey - t . ..  *.'? -1'*-. c 7  - 7-        1The radio operator at Fanay acknowledged                                                                                                                                                                                                                                           r. die? ted that                       reject: :^s he wished to transmit weather sequence reports based on.obseryatd                                                                                                                                                                                                                     one cov- piled                       - -* W - -. at 0400 G.C.T. by the Phi.lippine "Statiers and' relayed to hire in p                                                                                                                                                                                                                 ccordn.nce d??                       > .-. >w     :*>* i?..  <e j with Company procedure. The .radio operator on th                                                                                                                                                                                                                Clipper replied as follows "Stand by for one minute before sending as I                                                                                                                                                                                                                   in having tiwuhl .-. Mi yet with rain static."                                                                                                                                                                                                                                                                                        WSgS The radio operator in Panay                                                                                                                                        again-called the Clipper, at 0412 G.C.T.,ygiying; him the weather sequences,                                                                                                                                         Thi:s message Ws not. ackroviadgedW;                                                                                                   ; ; G x v-< 'w-^ operator at Panay continued                                                                                                                                        calling the Clipper until 0415 d.C.T.?; at which                                                                                       vx<. /- z- --v       :.. time he sent the Clippers                                                                                                                                  0400 G.C.T. position report to Manila.. At; Q435y G.C.T., the Comuni                                                                                           cations Superuitendent, rncific Di.vision,; .'lariu dy, Chlif was notified of the                                                                                             failure of communication between ground stations and tn                                                                                                                                                   *>* <rz.  Clipper. All                                                                      PhiVnnirra stations were requested to stand by on energy-ncy.                                                                                                                                                                          - < y-- c_":       . 4/<- communication                                                                      freouencies at 0449 G.C.T. This is a standard morgcrcprw^ dure which is                                                                      follviisd whenever there is an interniptior of comm^ tween shore s                                                                      ations- and - the .aircraft on which they are sending . interruptions                                                                      occur from time to time-and while they occasion no s._nr|                                                                                                                                                                   .: tz- emergency procedvr                                                                                              is put into effect as : a natter of reutihq.  c-iy oy  y. S<. r-',.J- Zr=> "Zk.-      090(1 G.G. 1.1 A..; w        vheliered that-<she-.^htebec!^S SB? lh?i&oW V iSs si i TiS . due th'3 &aval Comraandant,, ay. une reqv e- ..--,         yt'^n filBwd'WBseie W sWf* BreST 4 tofegfh v vessels were ordered to r^u^i:...anay^^^ to ;s.ea                                                                                                     C * T#--- {tnidniglrt>>i3 /vessels? w*?; search  o:r-:ithe  Sils sin                                                                                                                rcreft.. .: .                                                                                                                                                                                 so fl States    1 ynfd-lE,                                                                                           * -4* f* - ->*v > 'ZX ? :x->. *rri vin^ ? : in. MWSS&gO - Mbits- '5search was con                                                            v-.c t e d  in.  yt                                                                                                                      ......wsi A? *: -- :$>>    * .A- . -V  < .'.A-' ;f-. ;cil slick was discovered about                                                                                                                                                       28 miles south southeast of the ClipperVf last:estimated position. This                                                                                                                                                         slick was variously estimated by officere >bf -the Meigs to be from 500 to                                                                                                                                                      1,500 feet in diameter and roughly circvl ijn- shftpeP f..           '1 The area in the vicinity of the slick was carefully searched and a small bbat yas put ever in charge of Second Officer J                                                                                                                                                                              Harrington, for the pur- ijx-se. of obtaining samples of oil from the f                                                                                                                                                                    lick. Due to the limited amount ipf time before darkness, only a small sam.pl                                                                                                                                                                     & of oil was obtained. The Meigs xrwtoed hove to during the night in the hope of being able to pick up th flick again in the morning, The log of the Meigs shows that at the point the slick was found, there-.- was a current set of 14O0- True at the rate of about t daylight, one .knot per hour. At daylight, on July 31, the Meigs attempted to relocate the slick on the theory that bob                           the slick and the Meigs would hvc drifted approximately th                                                      same distance during the night. No sign of the slick was discovered and at 3:18 I-                                        Manila lime, the Meigs set a course to return to the original position of the oil slick. Another search'was made in that :>?; vicinity but no trace of oil-was found.                     ;  -                                                                                           .                              . .  31 : Following that time, in intensive search ever.a large area cf the ocean was conducted by the Meigs, Navy destroyers and submarines, and by ..rmy and Navy aircreft. Other surface vessels in that part of the Pacific lent their -t assistance. ;. search of the shores and interior areas cf I.uson and Mindanao, and other smaller islands of- the Philippine group, was conducted by Amy bombers arid Navy amphibians. .                                                         <;During the period cf the; search there was no surface winds reported ever 6 to 8 miles par hor, an-.I the sea was exceptionally- cslns. .This ccndi- itiofi tss ideal for th. search for small articles such as should haw. been 'floating ch f, he.-surface,' and the aircraft crashed in thatarea, or for oil, which, in tlie  eve nt of a crash, world bare bean released in large cniantities,The search was continued until August 5, at which tine the searchers felt thht W.: ry possible theory ns to. the location of the Hawaii Clipper had :bonu exhausted                                                                                                                            the. search was abandoned .. .In employee of                                                                                                                       - telephone company, whc> lives on the Island of Lahuy, is reported t<' have                                                                                                                       heard a large airplane flying above the clouds about 3    . Manila- Time.                                                                                                                       on July 29. As a result, of this report                                                        a careful serial  s^reh wsrer-e of the Island cf I.:ihuy and nearby areas*. It vres alsc ascerU  tailed that there wore xio imy, Navy or private aircraft in th t vicinity cn that date"eathc-r reports fro?: nearby Pan americ-.n :Aiiwuys fbaticns-indicate- that at l>hc time there was an <,va roast, with a ceiling of about 2,500 f e-.t, and ;M?ht rain4 \                 . / : a:.                   :Jahuy is a ^sall 5 si and' lying  East pf ,and close, to the Southeasteni  tip, directly on the course from the Clippers last reported ipcsi^on to Manila, normal creising speed the Clipper should have reached that, vicinity at ypproximfetoly 3:46 P*^. (ranila Time). Luzon is the . ip island -in the Philippine group. The fouthojn rfe rt-of Luzon and the: 'Kelli settled'. ' Itiere are, ar4aS'.cf tropical jungles and wvn.t.ai!i ranges which rise to :yre                -: ii. -reW / *: . , , f*r9 ./.. </   N>                                                                                                                                                                                                   ...irf _ A.sf--Xp. :' The sample of oil obtained few                                                                                                                                                                                                                                                                                                         sli ckths , placed        an tvr and delivered to the U.f.S, i*au3 . Jcrids,                                                                                                                                                                                                                                                                                                                                                                                                                                                       bS';.>SS- Ong' of - thi samples was testedlead content in Manila, The result was                                                                                                                                                                                                                                                                                                                                                              .Ggative, The residue of -this', pie and the untouched sample- were                                                                                                                                                                                                                                                                                                            ent to Neu fork for ccspl: to nnilysiThe., samples a                                                                                                                                                               unounted to less than 3 ccrs each,, which saa.tfe it.Mp^sMblc analyze in th                                                                                                                                                                 .e; usual manner; however, an investigtti on  of the pf- these samples                                                                                                                                                                 > v.ns conducted by chemists v.'bc ..r., selected for th                                                                                                                                                                                                                                                                                                                                                                                     " " . ..% " *                                                                     ^ in this particul                                                                                                                                                                                                            kind of work. At the cemplotian of those tes                                                                                                                                                                                                                                                                           wtar         to announce definitely that the oil recovered froin the\ site                                                                                                                                                                                                                                                                                                                                                                                                                                     Vfefe-hot  i '                                                                              A vf< type of oil used in the engines of the Ik.waii Clipper.The jfleigs amved in San Francisco while the Board ms that, point and before the laboratory tests had been made-,                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Tes^s.'ducted in San Francisco Bay in the presence of' officers'-of that vessel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              : y-z>- officials cf Pan American Airways Company tn an effort to identify th.-,;the slick. These tests consisted of dumping samples- of various kahdsi                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    :.: * -' <-7 : f' on the surface cf the waters of the Bay under conditions that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             '..'>. ?.s -:-r-; as nearly as possible, those existing in the Pacific Oc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   '/ >< '-  ' $ i^v       ' result                                                                                           of these tests, the following facts were ascertained- Any oil dumped on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            .w<S general appearanceThe odor of high test gasoline does not remain in artapil                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ---   /--- * -. ">       "'e slick more than a. for; minutes. This was ascertained by                                                                                                                                                                                                                                                                                                                                                                                                                                                                   > J\-V- . ._                    M. "  : '                 - < "v- -  drawing a cloth through the slick produced from the raiz- ture of used engine oil end 87-octance gasoline, The fladhered to the. cloth, but when dmv.n into the boat there   ' . -                            . .                       ...                   V?  . .                                                    .                   . \ *   % . was no noticeable odor of gasoline remaining,-even after so short a tine as? :ffc e minutes^-. Ibis- fact                                                                                                                                                                                                                                               is. r k n ti on e d. because the officars of the VMeig;s;-testified                                                                                                                                                                                                                                                 that                                                                                                                      a strew    *                                                *     *                           I         I  I                                                                                                                                                                                they                                                                                                                /  At A odor of gasoline .res noticeable at the tine                                                                                                                                                                                                                                                                                                                                                                                                              ..  y?1 yr: ? obtaining samples of oil from the. slick.                                                                                                                                                                                                                                                                                                                                                                                                                                                                       y.v.           i- .<'.-a         -%- .: v7.^? :>V-               X obtained ah ... 7  ... . . e rved 1 tS'.bChiructbristi.cS:-after ;jit hds>efeh plac ed in taro sit  wei^-sja^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         >- -.-.-is- 's* '                 - w :: w- -r '^.r                . .> . - ._>^. r_.., SJ ,^;x- '         6-f ff' ; Siiall samples of vara.cur-<bilSA-we:re., placed in :1ass ^&-^lled.-isitli sed'^tpre^^^^b^ksih.Aiip^ ahd-Tthe' '.result/was nharyd,fdr    , _ o * a * ,>  v*   * ,* %* ** " #                               ,      *, * * *  * *                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  r?i liracteristic beading, odor, color and tendency to einulsif                                                                                                                                                                                                                                                                                                                                                                                                                                                                      y.< i                                                                                                                                                                        h -. AS3JSS3 1.-th c'bservero,  non e of the:-. oil sq..treated -.appesMl                                                                                                                                                                                                                                                                                                                                                                                                                                                                  plica KT^ce:/.dr./h&             of the oil r-akcr f rem ths;                                                                                                                                                                                                                                                                                                                                                                                                                                            lleki'l/lt                                                                                           -  5 gjularly. hct'iceable- that in the cxpariSients made wit!                                                                                                                                                                                                                                                                                                                                                                                                                                       a>i rales; c   \ 7             A * -  - -- > * >   *.  :->V .z%*v- fed-/ &ig7h^;pily..'-.thp\bplo'r              to-be-radica'lly : -.di-Lj                                                                                                                                                                                                                                                                                                                                                                                                                                                 g^rii>-/rv*                                                                  thyOstf                                                                           ^..1'^v;-bilethkai<:f rc-m <ths slic^.         'was'; "board, the ''Clitf                                                                                                                                                                                                                                                                                                                                                                                                                                  e r; -12&                                                                      Jlqf^ Igine oil an: d a va rl fety                                                                                                                                                                                                                                                                                                            of other oils in small quan ti.ti                                                                                                                                                                        roforc.'-' fe event of a crash..the                                                                                                                                                                                                                                                                                                              engine oil would p re do- i in a -te.t r.                           Sif- ;.                               ?4 ; n- .w -   * - ?'?'' .- '....-^r'. .- w . ?:/, .-,<r? Zsvi7-s--.i ,-. ; : -' ;  * -* .' > S                                 ' :r :-  :W j-atxnjK./ycarc. - c-A-=AsJt  * -                                                                                                                                                                                                                                                                                                                                                                nil  in"' -'  * ' '    i-t-^T- 4.               O1?*-- 'At;V.-<-. ::  * ---* * - *  -*        ^* z kz .. * ' .... .*  .                                      - . - * -             - *  *^4 *r. / 7- * *%         -I- -     -%s . \         *                                                                                              .. ..-.^ v. <. .. ...... J , . w 4 -4                             .'-V - -  >'                   xy.--- y - hbat the - ........ ..... . --I' <- - '' * .1.. . &                                                                                                                                              * A-V-.         y.:  zj*'- \7,r-.. ysr-?---. >r. -- S;ha ;y" SS                                                                                                                                      '. <r-S'. ';. w a ^'. -K-                                                                                                                                ?>: / %<---Li   *        *                *. r . : *zT: ..?- . >'   <*  ?"<                                                                                                                            .? *r* . . iSi. 7 st r j r >ik- z$7f-   z>v aircraft and its equipaunt were in an airworthy condition when it departed from Guam. The flight was properly dispatched from to Manila in accord- S^^M^^rjcguiar Company procedure. Ifadio conditions; i.e. atmcspheric ccnditicns                                                                                                                                           re not unusual and. while .communication vdth the plane was occasionally difficult time during the trip from /lameda to Guam was ccmmvn? cati on 1                                                                                                                                            Tr.e flight Guam west proceeded no mall y, and the radic                                                                                                                                     cvipnent aboard continued . .satisfactorily until 0411 G.C.T. on July 29, lk'3^. 6* There was a failure, of communication but'.reen the Clipper and shoi^ statifizs immediately Tcllcwini-: 0411 G.C.T. ^ide-spread and intensive search by surface vessels and aircraft Lf&iledV'to -Msclost any evidence as tc the wh                                                                                      ruabcuts of the- Clipper. Tbc chemical analysis cf the oil. sa                                                                                                                                  xple obtained by the officers .b: A.T. Meigs definitely establishes                                                                                                                                         the fact that there is no con- ndetiou 5 be to Con the oil slick discovers                                                                                                                    by the and the disappearance of ^WkClipper^ . .<         / report from the Island of lahuy, that an aircraft was h<ard fly Ing in that vicinity above th^ clouds cn the afteinoonof J-ly 29, cannot be ignortyd.. 10.  Due to the character of the terrain, the Board is not prepared to say' that the aerial search of I.ahuy and other areas in the islands can be con siJorcc as conclusive. 11.  Tv:.- rerz?-rd offered by the Pan American -ir^ys Company for infenna- tibri' COTcendne, the-Clipp.r. should .stimulate th: slearcb^ by. land, an d may pro- duce results conclusion, it. appo-ars that the- only                                    efinitc facts established.up to th'. prushnt time, aiv ?-^t botwecn 0411                              arw -0412 G.C.T. oh July wasfe fail.u.^-?;cf ^mvnc?tion b-. tween the                              ground and the Clipper? net th  rafter .reestablish^                                     nJ that he Grace of b.lw8 discovered. - A mhnburef thcori                   os have bo.n navanced itaBB basic c'Mse of or reasbn for                                                                                    SwRUaHMM the pcssibl.                                                                                                                                            disappearance of the- Ills S'?. rd hr                                                             considered each cf them. * S                                               ave net been have 1                                                                Contradicted by the k^ctxi facts                                           < W' jt, t  ;C In vest! gz t jewels that this report                                                                                        ar'nc't prcpcrly include                                         sevsshon of unsupported by developed facts,                                                                                             lie Board,, ti                                      re, respectfully this report>n th the thought th                                                                                               add! tior.ri                                                        t be dxs^^^l and the investihcti.cn completedit b.rt b See our selection of aviatioon documents at RareAviation.com fOR IMMEDIATE RELEASE January 9, 1940AIR SAFETY BOARD Civil Aeronautics AuthorityWashington, D. C.The crash of a Pan American Airways' bm-engmea flying boat at Rio de Janeiro on August 13. 1939. vuith fatal injuries to all hut wo of the sixteen persons aboard was attributed by the Air Safety Board to "loss of power fromthe left engine during the landing approach, necessitating an attempted landing under extremely hazardous conditions" in a report transmitted to the Civil Aeronautics Authority and made public today.The accident occurred after a scheduled air line flight from 2a.ari through the West Indies and down the east coast of South ..merica, the last leg of inchvas from Victoria, Brazil, to Rio. The report said that tne aircraft nad cir- cled over Rio and was making a normal approach to tne seaplane landing area ad- joining the air line's Rio hase, m accordance with the company's estaolisned operating procedure, when it suddenly lost power fro 1 the left engine, yawed to the left, and started a descending turn in the sane direction.The airplane continued to lose altitude and to turn at a sharper and steep- er angle until it struck a caisson anchored at right angles to a small island in the harbor immediately adjacent to its landing approach path. All four members of the ere and ten passengers .-ere fatally injured m tne accident                              one pos- 1 senger escaping with serious ano anotner with minor injuries.Ample evio'ence was obtained during the Air Safety Board's investigation of the accident that the left engine suffered a sudden loss of peer at a critical time during the landing approach, although, since a-f? liable evidence failed tosupply any conclusive explanation for this loss of power, and a detailed exami- nation of the engine, after disassembly, revealed no indication of structuralfailure or mechanical defects in flight, the report stated that "the cause of the loss of power from the left engine is unknown." Sailors fro^ the Brazilian battleship, >imas Geraes, anchored nearby, /ho iiiriodinely s am or roi cci to tne scene of the accident and participated in firefighting and rescue activities were praised by the report for having demonstrated "a hign ucgrcc of courage."A copy of the full report is attached. File No. 1353-39AIR SAFETY BOARD REPORT I TO THE CIVIL AERONAUTICS AUTHORITY OF AN INVESTIGATION OF'AN ACCIDENT INVOLVING nIRCRABT Accident involving aircraft NC 16933 of Pan American Airways, Inc., near Rio ds Janeiro, Brazil, August 13, 1939. An accident involving aircraft of United Stages registry NC 16933, hile operating on scneduled trip of Pan American Airways, Inc., having occurred in the vicinity of Rio de Janeiro, Brazil, on the 13th day of August, 1939, in th , the resultant destruction of the aircraft and fatal injuries w all but t^o of the sixteen persons aboard, the Air Safety Board of tne Civil Aeronautics Auth- ority directed that full and complete investigation of the accident, pursuant to the provisions of Section 702(a)(2) of the Civil Aeronautics Act of 1938 (52 Stat, 973, 1013), be immediately begun, and that the facts, conditions and circumstances relating to the accident and tne probable cause thereof bo deter- mined. It was further ordered that the investigation induce such field in- vestigation and research and such public or pnvauc nearing or hearings as might be considered necessary. Tor the purpose of carrying out the abo^e order, too Air Safety Board designated G. C. killer, Chief of the Tecmical Section of the Air Safety Boarci, as investigator in charge, and Meed M. Glass, Chief, Examiners Section ol the Air Safety Board, as legal adviser to the investigator m charge during the field investigation m Rio de Janeiro, ana as Examiner empowered to order ano conduct such public or private hearing or hearings in connection ''iuh tno in- vestigation as the Board might direct. Investigation of the accident was begun in Rio de Janeiro on the 24th day of August, 1939, and the public hearing in connection there,it.i vas orccreo and held in the city of J_iani, State of Florida, on the 3rd and 4tn ctaj s of October, 1939, and reopened in the city of Washington, District of Columbia, on the 6th of December, 1939. Mr. Glass and Ur. filler were assisted and advised during the public hearing, which was conducted under the personal supervision of Thomas 0. Hardin, Chairman, Air Safety Board, by Frank E. Caldwell, Chief, Investigation Division, Air Safety Board. Having considex-ed the evidence adduced m the investigation and the reporu of same made to the Air Safety Board, the following facts, conditions and cir- cumstances relating to the accident end conclusion as to the probable cause thereof arc hereby reported to the Civil Aeronautics Authority pursuant to the provisions of Section 702(a)(2) of the Civil aeronautics Act of 1938: FACTS, CONDITIONS, AND CIRCJiSTANCES Pan American Airways, Inc., a corporation organized and existing by virtue of the laws of the State of Nov York, having filed application for Certificate of Convenience and Necessity, pursuant to the provisions of Section 401 of the Civil Aeronautics Act of 1938, over certain routes including a route from Miami, Florida, to Buenos Aires, Argentina, operates as an air carrier engaged in 2foreign, a                                                                                                                                          commerce between such termini, via certain named intermediate points carrying passengers, property and mailA regular scheduled trip of Pan American Airways, Inc., departed Miami, Florida, on Wednesday, August 9, 1939, enroute to Rio de Janeiro -with scheduledstops at Antilla, Cuba; Port au Prince, Haiti; San Pedro de Macons, Dominican Republic; San Juan, Puerto Rico; Port of Spain, Trinidad,                                                                                                                                             Trinidad, Georgetown, British Guiana; Paramaribo, Dutch Guiana (Surinam); Cayenn                                                                                                                                            French Guiana; and the following points in Brazil:                                                             Belem, Sao Luis, Luiz Correa, Camocim, Fortaleza, Areia Branca; Natal, Joao Pessoa, Recife                                                                                                                                      Inceio, Aracaju, Salvador, Cannavieira^ Caravellas, and Victoria                                                            In command of the trip ;<as Captain Audis on G. Persons with a flight crew consisting of Captain George B. King                                                                                                                                               Co-pilot in charge; Russell Jenkins, radio operator;                                                                                    and Julio Trujillo, steward.Captain Persons had been m                                                              the employ of Pan American Airways, Inc., since June 21, 1929, during which time he had accumulated a total of approximately 10,800 hours of flying time, approximately 560 hours of                                                                                                                                               hich had been in Sikorsky Model S43 and S43B aircraft                                                                                                                    V'ith the exception of a five-month period in 1930, Captain Persons had floim in the capacity of Captain during nis entire experience 1 ith Pan American air- ays,                                                                                                              Inc. Captain King had been in the employ of Pan American Airways since October 2, 1933, during vh ch time he nca accumulated a total of approximately 4,275 hours of flying time, approximately 830 hours of which were in Sikorsky Model S43 ana S43B aircraft. Captain King's experience had been in the capacity of Co-pilot prior to February 23, 1937, on which date he was promoted to the rank of Captain. His experience since that date included eight months' flying as Captain on regular operations of Panair do Brasil, an affiliate of pan American Am ays, Inc., from November, 1937, to JW, 1938. Captain King Las based in Rio de Janeiro during this entire time. Botn airmen were possessed of required ratings and certificates of competency for the flight and equipment involved.Although Captain King had flown the 4uami to Rio de Janeiro route and had been approved as competent and authorized to fly various routes of tne Eastern Division of Pan American Air; ays, Inc., such a period of time had elapsed sincehis last flight over part of this route that r gulations of both the Civil Aeronautics Authority and Pan American Airways required a familierizavion flight over the route before he could be authorized to fly between uhe two points in the status of Captain,---' In accordance ; ith regular coipanv procedure in such1/ Provision No. 61.5140 (a) of the Civil Air Regulations:"Regular route. After 6 consecutive months* absence from flight duty over a regular route, or part thereof, a first pilot -all n0 longer be deemed competent for the carriage of persons in air carrier service over such route or part tnereof. familiarization flights, Captain King 'as assigned to the flight herein in- volved as "Co-pilot in Charge.2/ The flight proceeded without, incident to Port of Spain, Trinidad, arriv- ing during the afternoon of Thursday, August 10, 1939. A Sikorsky I Iodol S<2 aircraft t as used on the flight to Port of Spain but at this point the equip- ment tos changed and the flight was continued tho next morning by Cap to in Persons, Co-pilot King, Radio Operator Jcnkms and Steiaro. Trujillo in NC 16933, a Sikorsky Model S43 (flying boat) aircraft of United States registry, manu- factured by the Sikorsky Aircraft Division of United Aircraft Corporation, Bridgeport, Connecticut, under date of December 20, 1936. NC 16933 had been approved by the Civil Aeronautics Authority for air carrier operation over the route flown by pan American Airways, Inc., between 'iami and Rio de Janeiro with an approved gross weight of 19,500 pounds. It vas powered with uuo Praut and Lhitaey Model SEG Hornet engines, Serial Nos. (loft) 2824 and (right) 2825, both rated at 750 horsepower, and Hamilton Standard Constant Speed pro- pellers, hub Models 3E 50---211 and blade Models 6105 A-18. The aircraft at the tune of departure from Port of Spain had been operated a total of 3650 hours and 12 minutes, while both engines nad been operated a toual of 1399 nours and 52 minutes, 353 hours and 38 minutes of which had been since last overhaul^/ NC 16933 had departed Miami, Florida, on August 3, 1939 under the command of Captain Weber on regular scheduled operation of Pan American Airrays, Inc. and had arrived in Port of Spam on August 10, 1939 after navmg operated on various scheduled trips in the test Indies. Four ICO gallon main tanks and fa o 55 gallon reserve tanks installed in NC 16933 gave the aircraft a total gasoline capacity of 510 gallons. Tne in- stallation of the entire fuel system, including these 6 tanks, of NC 16933, is illustrated on a blueprint drawing of this system designated Appendix A, at- tached hereto and made a part of this report. It is to be noted in connection with such installation that outlets from both main tanks supplying each engine 2/ Pan American Airways, Inc. Circular Memorandum No. 449, executed under date of August 18, 1938 by Edimar d P. Critchley, Operations Manager, Eastern Division, in effect on the date of this flight, provioes. ,rWhen a pilot on an airline training flight has been desig- nated *Co-pilot in Charge he is under tho direct supervision of the Captain. The Co-pilot m Charge will make all landings and take-offs, set all courses, and make all corrections for courses. Hoover, if in the opinion of the Captain there is the possibility of the slightest error being made it is to be clearly understood that the Captain is m charge of the flight and his orders are to be carried out by the Co-pilot m Charge ith regard to landings, take-offs, setting the course, etc.3/ Approved overhaul period for this model engine for the Eastern Division of Pan American Am/ays, Inc. is 500 nours. * passed through one valve and that the pilot could switch only from mam tanks , to the reserve tank and could not         select between            Piaui tanks to the same engine,, Each mam tank, as is to oe further noted, had a                     float valve, the purpose of which was to close the outlet from the tank when                    the gasoline supply became                           ex- hausted and tnus prevent an air Lock m the fuel                     lines. Experience of Pan American Airvays, Inc., however, with this installation had resulted m toe                                            de- cision to eliminate these float valves and change                                     he selector valves so as        tc enable tne pilot to select between the tiro main tanks to each engine as well as the reserve tank. Detailed drafting of such revised fuel system installation is also illustrated in Appendix "A. Although such changes had been made in several similar aircraft operated by Pan American Airways, Inc., no change had been made m the fuel system m NG 16933 as illustrated herein in Appendix A.11The trip proceeded on Friday, August 11 to Belen, Para, where the aircraft received the regular overnight inspection check and a complete chapge of spark plugs. The next day the flight continued to Recife via scheduled intermediate points where another scheauled overnight stop Tas made and the aircraft again serviced in the company's shops at that point..Scheduled departure was made the next morninc, Sunoay, August 13, 1939 and the aircraft proceeded toward Pio de Janeiro landing at naceio, Araca^u, Bahia, Caravellas and Victoria. Computations based on company records of the flight indicate that the average fuel consumption of MC 16933 on the operation from 1 lami, Honda, to Port of Spain, Trinidad, mas 83.9 gallons per hour; from Port of Spain to Victoria vas 84.6 gallons per hour, and over the entire operation from Inarri to Victoria was 84.3 gallons per hour.The plane departed Victoria, the last scheduled stop before Rio de Janeiro^ a distance of approximately 300 miles to the south, at 2:31 P.h. with a gross weight of approximately 19,000 lbs., including gasoline, mail, property and the following passengers, who gave their addresses as indicated-Henrie May Eddy, Evanston, Illinois, U.S.A. James Harvey Rogers, California, U.S.A. Robert Landman, Kansas City, Missouri, U.S..., Evans to Gomes Miranda, Recife, Brazil Anton Ctanundsen, Jr., Rio de Janeiro Emanuel Valensa, Rio de Janeiro Pablo Lavin, Buenos Aires, Arg. Edgar Belly'Oliveira, andarahy, Bahia, Brazil Alberto Oliveira Santos, Victoria, Brazil Lucila a. Oliveira Santos, Victoria, Brazil Os--aldo Hirth, Rio de Janeiro Mario Souto Lyra, Bahia, BrazilAccording to records of the Victoria Station and other availaole evidence 120 gallons of 87 octane fuel was taken aboard' at this point, making a totalof approximately 275 gallons of gasoline aboard at the time of departure, dis- tributed m the following manner- 50 gallons in each of the two msiae main tanks, 50 gallons in each of the two reserve tanks, and the balance m the two outside mam tanks (designatea in Appendix UA" attached hereto as tanks 2, 3, El, E2, 1, ana 4, respectively).3sty leather conditions enroute were favorable and the aircraft proceeded to Rio de Janeiro in scheduled time, reporting by radio at 4 2G F.K., one hour and 49 minutes after departure from Victoria, that Rio de Janeiro hao been sighted.  eathcr conditions at Rio de Janeiro at the time i ere clear with unlimited visibility. Landing conditions reported to the aircraft as it ap- proached the city were "imd soutn southeast six sea choppy Kollsman 30.16." The aircraft approached Rio ae Janeiro at approximately 4.30 P.i . and Heir directly over the city at an altitude cf approximately 2000 feet and gradually circled to the left passing back out to sea and flying over Nicthcroy, which is in an easterly direction from the landing area. The fligjit then proceeded for some distance in a northwesterly direction, gradually losing altitude dur- ing the maneuver until an altitude of approximately 500 feet -"as reached a mile or so northwest of the landing area. At this point the aircraft- turned 180 and approached the landing area in a normal glide. According to- company per- sonnel, the approach of NC 16933 herein described is the normal procedure in landing international flights at Rio de Janeiro, and is followed mainly for the purpose of giving passengers an aerial vie of the city and harbor before landing. Official sunset at Rio de Janeiro on the day of the flignt ws ap- proximately 5:35 P.h. The lancing area to be used by NC 16933 lies between the mainland and an island, Hsia dos Cobras, hich lies a short distance off the mainland to the northeast and is connected with the mainland by the bridge Alexandria. The use of this area is prompted mainly by its freedom from sells ano proximity to Pan American's landing base, though as is to be noted on the dra-ing of the area attached hereto as Appendix "B" and irade a part of chis report, its use necessitates an appro?cn over the bridge Alexandria, the top of - hich is 33 feet above the surface of the water, and a turn of approximately 10 to 15 shortly after passing the bridge before leveling out for the landing. anchored just off the quays along the northest side of lima dos Cobras to the left of the flight path of NC 16933 ere a diving oell end caisson, and just oeyond on the northeast side of the island, i as the Brazilian battleship, ihnas Geraes, designated a, B, and C, respectively, on appendix "B" attached. The diving bell, which >as located some 600 feet to the loft of the flight path of NC 16933, was approximately 100 feet m width, 85 feet m height and extended out from the eage of the island for a distance of 145 feet. The caisson, which -was constructed of steel, iron and concrete and was the floating ena of a nearby drydock of the Brazilian Navy, was anchored some 18 feet off shore at an angle of approximately 75 to the shoreline, and a distance of 60 feet to the northcast of the diving bell. The caisson measured 123 feet in length, one the top deck, which was 18 feet above the Cter, varied in width from approximately 12 feet at each cue to approximately 20 feet in the center. The .iinas Geraes, Brazilian battleship, was moored alongside the quay on the northeast side of the Ilha dos Cobras, a distance of approxiWtely 185 feet beyond tne caisson, with the bow extending out fro  the nortnvest corner of the islana for approximately half the distance of the caisson. The faredeck of the Linas Geraes i as only a fei feet higher above the surfc.ee of the -water than the top of the caisson, although tne superstructure of the battleship, ihich -was c short distance back of the north? est'corner of the island at the time in question, rose to a height of approximately 170 feet above tne surface of the inter. See our selection of aviatioon .documents at RareAviation.com *" OThe approach of NG 16933 continued toward the bridge Alexandria in a normal manner along the line of flight designated on Appendix "B" by the lanefrom point D to point E until a position ires reached, designated on Appendix "B" as point F, a distance of some 800 feet from the bridge Alexandria at an altitude of approximately 145 feet. At this point tire aircraft suddenly yav cd to the left and began a gradual descending turn m tins direction which be- came sharper as tho aircraft progressed. Tho turn continued until the aircraft stalled just before reaching the caisson and struck the caisson cclo1' the top and jusx. back of the northcast end. The right motor struck an iron capstan on top of the caisson, broke loose from the aircraft and rolled between two iron bitts on tho end of the caisson where it wedged itself                      Tho hull of the air- craft split open just aft of the leading edge of the i mgs                      and numerous parts of tho hull, right tang and interior of the                 aircraft i ^rc strem about the top of the caisson. A largo part of the right vang and part of the interior of the cabin struck the water on the opposite side, while the remainder of the hull and contents, left engine and left wing dropped into the water on the southwest side of the caisson. Fire broke out immediately following impact and the top of the caisson was soon a mass of flames. Sailors on tho Ainas Geraes immediately swam and rowed to tho caisson and .uh toe aid of fire ex- tinguishers and -water hose finally extinguished the blaze, alunongh a con- siderable part of the aircraft was destroyed oy tho Fire p-fore their efforts were successful. Personnel involved in the fire fighting and rescue activities demonstrated a high degree of courage.The left; engine and wing, bow of the plane, instrument boaro, and numerous other parts which either dropped into tho voter on impact or i ere tlicn into tho water from the top of the caisson during the rescue ; urk, sani: to tho bot- tom. The hull and right wing, ho^fcvcr, remained afloat long moegh to be tovec to shore.The accident resulted m the death of everyone aboard the aircraft with the exception of two passengers, Osvaldo Hirth and liario Souto Lyra. The former sustained serious injuries although the latter - ^s only slightlj in- jured.Although conflicting m the detailed descriptions of tho maneuvers of the aircraft subsequent to the tune the left turn above described was begun, testimany of -witnesses indicated that only one engine  as operating during the torn but that this engine was apparently operating at high r.p.m. until the noise ceased just before the aircraft struck tho caisson. Testimony of survivors indicated that there was no excitement aboard the aircraft prior to impact and that conditions wore normal in every respect.Divers began work the next morning in bringing to the surface all parts of the aircraft on the bouton. Such operations continued for several daysand nth the aid of several boats, such parts, as -well as wreckage and debris from the surface of the water and top of the caisson, - ere removed to the panair do Brasil hangar. Detailed inspection was then made and readings taken by company personnel of various instruments, controls, ana component parts of the wrecked aircraft. The general condition of the instruments, however, and the fact that many of the instrument hands moved freely after salvage prevented > any importance being attached to such readings,3S7 The flap selector valve, though badly burned, indicated a "flap den 11 setting at tune of impact. The tank selector valve of both the right and left engines was set on reserve tanks. The individual engine shut off valve of the right engine was in the off position, although definite indications were that this valve setting had been moved during impact. The right engine fuel punp was m an inoperative condition due to damage by fire. The left engine fuel punp, however, -'as not touched by fire and tests were run to determine its operative condition. On the first attempt the pump would not operate, although on removal of salt water, salt crystal and a small amount of dirt found under the relief valve, it funcbior.ec1 normally. The right carburetor vias crushed by impact and badly burned by fire. The left carburetor, however, was found on disassembly to be m good order 'except for corrosion. The butterfly valves of this carburetor were found to be closed, although no importance was attached to such condition as they moved freely. The fuel cross-over valve was found to be closed. The ignition system was so baaly burned that no determination could be made as to its condition ax time of impact. On subjecting the engine control panel to close examination, .evidence was found that fire had reached the common shaft of the control bellcranks v-hile that part of tne aircraft remained m the fire area on to2i of tne caisson, and had frozen the segments on it. hnen the cockpit broke (presumably when it fell from the caisson into the water) all controls wore pilled aft by the then frozen11 bellcranks. Such condition would indicate that at the tne of the accident the throttles  ere on; propeller controls i ere m low pitch1, and mixture controls were full rich. The condition of the wreckage when spread out in place on the floor of the Panair do Brasil hangar definitely indicated that fire was most intense on the right side of the aircraft in the vicinity of the right reserve fuel tank. The right wing, aileron and right side of the flap -'ere badly burned while the left tang showed no sign of fire except in the immediate proximity of the left nacelle. All parts of the flap, -hich was found in ufull do/h posi- tion, and ailerons were accounted for except a fe~ feet of the flap to the right of the center Ime of the aircraft. Both the right and left propellers -ere found in position on their re- spective motors. The right propeller and right motor remained on ton of the caisson and were damaged only by fire and impact --^hile tne left engine and latter propeller remained under water for 24 hours. Inspection of the blades of this/ propeller indicated that it had suffered very little damage. The only appre- ciable damage, a 90 bond in No. 1 blade, was done then the motor and oropcller were lowered on shore by the crane during salvage operations. It was found necessary to hammer the counter-height bracket to; ards high pitch in oraer to dismantle the propeller. No. 1 blare i^as found to have been forced in a posi- tion about 40 lower than normal lo;. pitch and several indexing teeth, bushing screws, and dowel pans \ ere found to be sheared. No. 2 blade ias slightly born, ano ;ras 40 past normal high pitch. Bushing sere s, dowel pins, ana in- dexing teeth of tins blaae -cere also found to be sheared. No. 3 blade was slightly bent and was found to be in normal lo-r pitch. Bushing screws, do1 cl pins, and indexing teeth irerc normal. The cylinder was found m normal low pitch and apparently suffered no damage on impact. Inc condition of no. 1 and No. 2 blades, and the fact uhat No. 1 blaae sheared tne pm towards lo'j pitch and No. 2 blade sheared the pans toward high pitch, would seem to indicate that the propoller, while turning slowly or not at all, met an obstructionbetween these two blades, ihich, when the weight of the motor boro down, pushed, one blade toward high and the other toward low pitch. Tho third blade remained unchanged. The condition of the propeller was of such a nature as to indicate that the left engine was putting out very little, if any, power at time of impact.The right propeller suffered                                                                                                                      much more damage on impact than did tne left, The No. 1 blade was broken in two                                                                                                                  about 18" from tne tip and i as driven about60 past high pitch. Several indexing teeth were sheared,                                                                                                                        and bushing screws and. dowel pins were sheared off. No. 2 blade was bent and                                                                                                                         a piece about 4wide and 10" long torn out about 15 from the tip                                                                                                                            . Tne blade was past high pitch about 60 and bushing screws, dowel pins,                                                                                                                   and several indexing teeth were sheared                                                                                                                No. 3 blade was turned a full 180 from normal high pitch; blade bushing screws and pans were sheared; and indexing teeth were sheared all around                                  The counter-weight brackets of ilo. 2 and No. 3 blades were broken off and No                                                                    1 and No. 2 blaoes were dented in such a manner os to indicate that the leading edge struck first, while No. 3 blade nad deep dents on the tiailing edge. The head of the cylinder vis forced off by tho impact, which also forced the cylinder into high pitch. The general condition of thxs propeller, parti- cularly the deep dents and cuts on two blades, irould seem to indicate that the right engine was turning at high r.p.m. at time of impact with the caisson.Both the left and right motors were then torn down, ana on detailed exami- nation ana inspection were found to be in the follmang conditionsRight Engine. All cylinders showed signs of intense external heat. On two cylinders the exhaust and on one the intake rocker arm housing was com-pletely knocked off.                                                                                      The power section appeared to be in order except forsigns of intense heat                                                                                     on the outside. The sump was broken in such manner as to indicate damage by                                                                                     impact. The nose section was cracked and the nose sec-tiop fixed gear bolts                                                                                     werc sheared. All push rods cro bent .and housings were badly burned and crushed. All sparx plug insulators were burned away. Two teeth of the impeller reduction gear were broxen off and subsequently found in the housing. AU breaks were clean cut and of such a nature as to indicate that tncy were due to sudden stopping of the engine while operating at a high degree of power output. The intake manifolds and carburetor were badly burned and crushed. The rear plug insulators were burned away and all accessories were badly burned.Loft Engine. No evidence Of extensive fire -/as found m this motor ex- cept some scorching of front ignition harness, earning of iront plug insu- lators and drops of molten aluminum on hoaas and intake manifolds of No. 2, 3 and 4 cylinders, where the cowling -was burned away. All co-"ling fittings on the rocker boxes were knocked off ana No. 5 cylinder intake and exhaust rocxer housing vs broken.                                                                                     Some push rods were bent but indications were tint thiswas done                                       m salvage.                                                      The                  nose section, rear section, accessory section, re- duction gearing and power                                                                                                           section appeared to be in good condition. The crank- shaft turned freply. All                                                                                                            cccossoncs were in order but quite corroded from salt wafer. The sump was                                                                                                            broken but the evidence indicated that this was also done m salvage. The impeller showed very slight scratches. The engine mount' was bent and broken, and two lower members vore brexon in tension vnilc tiro3sij From PilotManuals.com / RareAviation.com upper left side (outside) members wore bent m compression. All indications were to the effect that at least the bond of the upper members .rs due to a blow on No* 5 cylinder directed upwards end towards the left of the rotor. The oil radiator appeared intact except for salt ^ater corrosion. The condition of the engines, especially when consideration is given to the condition of the respective propellers, indicates that the left engine vus putting out little, if any, power at the tine of impact, while the right engine was still operating at high r.p.nu Based on the 84.3 gallon per hour fuel consumption of NC 16933s engines from Miami to Victoria, it ims estimated that the aircraft ^ovla have con- sumed 175 gallons of gasoline during the two hours and four minutes that elapsed between its take-off from Victoria and its crash at Bio de Janeiro. Since company records showed that approximately that amount of fuel \as con- tained m the aircrafts main tanks when it took off from Victoria, the pos- sibility was considered that these tanks nay hav< run dry at a critical tine during the landing approach, thus starting the series of events which resulted m the accident. Ho'evcr, os both tank selector valves -wro founa turned on the reserve tanks, no conclusive evidence is available, particularly m vici of standard company approach procedure^/ to indicate or substantiate that the striking parallel between the computed consumption of the flight and the esti- mated amount of fuel in the main tanks hod any bearing whatever on the outcome of the trip. The plausibility of accounting for the accident on this theory suffers still further because of the known variation m the aircrafts fuel consumption on various legs of the flight from Fauna to Victoria. Several other possible causes for the failure of the loft engine, such as carburetor ice, etc., have been given exhaustive consideration. However, since there is no conclusive evidence to indicate the presence of any one or conoma- ticn of such factors, the cause of the failure of the left engine of NG 16933 must remain undetermined m the absence of more informative and conclusive evidence than is nor available. <7 Pan American Airways, Inc. Circular Memorandum No. 330 issued August IS, 1937 by Edward P. Cntchley, Operations Eonager, and in effect, on the date of this flight, provides: Operating Procedure - S-43 Amphibians 0n the S-43 amphibians equipped with four mam tanks and tv.o reserve tanks, a minimum of 35 gallons of gasoline will bo carried in each re- serve tank leaving any pert* Prior to arrival at any port, ano. preferably at the Time uhc mstruront check is made, the gasoline tank controls "-ill bo switched to the re- serve tanks so that the landing will be made taking fuel froi a source not affected by fluctuations of engine consumption or unknenn errors of measurement, cither mechanical or human, at the same time permitting a switch back to the mam tanks if there is any mal-functionmg of the re- serve tanks. - 117. The aircraft circled the city of Rio de Janeiro and began mo ap- proach for landing in an ar=.a bet1 eon the mainland and Ilha dos Cobras an a manner consistent iith the general operating procedure of the company at this point.8. The approach was normal until the aircraft, flying at an altitude of approximately 145 feet, reached a point approximately 800 f. ct distant from tile bridge Alexandria, 'hich connects Ilha dos Cobras and the mainland. ?*t this point the aircraft ;>aued to the left and began a gradual descending turn in this direction which continued at a sharper and steeper angle until just before it struck a caisson anchored off the northest corner of Ilha dos Cobras.9. The aircraft crashed at approximately 4:35 P.L.10, The accident resulted m destruction of the aircraft by impact and fire, minor injuries                                                        to passenger Mario Souto lyre; serious injuries             to pas- senger Osvaldo Hirth,                                                       and fatal injuries to the other 14 occupants.11. Personnel involved m the fire fighting and rescue activities demon-, strated a high degree of courage.12. Available evidence indicates that the initial yaw to tnc left                                                                            i as caused by loss of power from the left engine and that the aircraft cs                                                                       mam- tamed m a controlled gliding turn following the initial ya r to the left The cause of the loss                                                           of power from the loft engine is unKnor-n.13. Testimony of witnesses and the condition of the propellers end engines of the aircraft after tie accident indicated tint the right engine was operat- ing at high r.p.m. and that. the left engine was turning at very lo,r r.p.m. from the tine the air-craft began the turn to the left until it crashed into the caisson.rapidly and yaw ten ard the inoperative engine in the event single mgme flight is attempted with the flap down.15, Evidence adduced during the investigation mdice ms that the aircrafts turn to the left in continuation of rhe initial yaw 'ras tf.c result of thepilots decision to attempt a landing m the inter to tnc left of tnc original flight path, which attempt proved to be beyond the operating capacities of NG 16933 under flight and other conditions existent at the time. Further in- dications are that other available choices wore likewise beyond rhe operating capacities of NO 16933PROBABLE CAUSELoss of power from the left engine during the landing approach necessi- tating in attempted landing under extremely hazardous conditions.From PilotManuals.com / RareAviation.com See our selection of aviatioon documents at RareAviation.com ____~.n---* FUBL SYSTEM OF NC-16933                      f?gvts,o FUSX SYSTEM AKtSJCAM ALWAYS, 4nc.,  S-^3 Al^C^AFVfeti r u' ttNQINt                                                  tNttIMtrv           3-WAY YALVE 9- 1O V^oeSLE. PUM.P SHUT OFF VALVE0 ?-WAY VALVE CHECK VALVE 0 2-WAY VALVE.  $HUT OFF VALVE O WoSBUE. PUMPAPPENDIX Wy- CIVIL AERONAUTICS BOARD WASHINGTON, D. C.FOR RELEASEMay 24, 19412248-40LOSS OF CONTROL UFILE IL'DCYING CLUSES OCCIDENTaccident occurring necr Maracaibo, Venezuela, South xjnerica on July 24, 1940, was caused when the pilot lost control of the cx.craft while taxying to the loading ramp, the Civil Aeronautics Board reported today.The aircraft, operated by Pan. ^Jnericon ^ir'wcys.                                                                                              Inc., New York, New York, was a Douglas DC3a-S1C3G, NC 25657, powered by                                                                                          Pr^tt & Jhitney engines S1C3G left motor 251.43 Horsepower -                                                                                right 510tor        251.43 horsepower. The crew was as follows:Captcin                                   Clifton Virne George with 3844.32 flying hoarse. First Officer                                           Robert Rene Delareuelle with 1695 hours Radio Operator                                          Michael H. McFarlan Flight Steward                                          John Tendick Passengers                                              Frank Weiss of Carapito, Vene^iela - Pierre Boyle, Maracaibo, Vene&iiela -Jose del Carmen Carrasquero, a native employee of Pan jjierican nir- ways, was fatally injured when struct by a propeller as the Douglas airplane was being taxied to the loadin' romp at the Mmacaibo Airport, Maracaibo, Venezuela.Subsequent investigation disclosed that the flight crew hod dis- covered a leakage of hydraulic fluid from the vicinity of the hydraulic system pressure gauge shortly before arriving ct Coro, the last intermediate stop before Maracaibo. Tne leakage apparently stopped when the hydraulic pressure decreased upon lowering the landing ge'r. The 1-ending nt Coro had been effected and. the indicated 500 pounds pressure rem imng on the hydraulic system hud sufficed to decelerate the -irpltne in n normal manner. The flight crew elected to continue tne flight tc Maracaibo, the terminus of the days flight, witn the landing gear remaining extended.Upon arrival nt                                                                                           Maracaibo a normal landing was mode during which landing flaps and cowl flaps operated normally                                                                                         After completing the lending roll the brakes were tested                                                                                    nd found to function noimnlly, whereupon thepilot slowly taxieu toward the p                                                                                  error platform located in front of the hangar This necessitated r movement                                                                    in a southerly direction with a crosswind from the East. To keep the nircr                                                                     ft from weathercocking to the left into the wind, the toil wheel was locked in                                                                    a neutral position and the loft engine operated under greater povrer tnan the                                                                   right (over) CIVIL AERONAUTICS BOARD WASHINGTON, D. C.FOR RELEASE:Amnn; on the apron in frvnt of the hangar, the tail wheel was un- locked to permit the -ircraft to be turned to the nrht with the tail toward the han-ar duors which was tic usual unloodiiw position. H^ever, immediately upon unlocking the t.il wheel tie aircr ft ter?n to wea .he,-*cock         t~ th? left toward the closed hanrar doors -<hc,re three men of the servicin'* crew were stonom^. Traces were ip plied but i*;er^ found to be inoperative. Th pilot cut the Piaster switch ana the mast.r controls were moved t< the icle cut-off position. The left wizv tij struck thv h-,n,or first, swin^ira the aircraft further to the J ^ft and toward the servicinr crevz wh' wc re directly in the path of the left propeller which w-<s still turnm  from its momentum. T\\c cf tho crevr jumped cl^ar while th* third man wa* struck by the rcvclvmr propeller o,s he stood watohmr the left win,; ti; hemp crushed ir^inst the hangar. He received injuries which prove J fatal. The left -'/in; and center noso section of the aircraft wvrt damaged extensively. Inspection of the hydraulic system discKecd ob t t-e oil nrocrure nr. the brarc system was lost due to a broken tube flare t tnc left cowl flap control valve, thereby rtnd^rmr tr.o wheel brake sechanism inoperative.A subsequent investigation disclosed that the fatally injured man had been employed by Par American Air^eys, Inc., r-ly t/zel^e ^ayr, prior to the accident.PROB.PLE CAUSE: Pilot lost a. ntrol sircrcft while taxyinr to Iodine ramp due tn cross wind end i/jcx^r- tiv, vzheel brekos.* * < * * * CIVIL AERONAUTICS BOARD WASHINGTON. D. C.FOR RELEASE REPORT. 0? EG CIVIL AAROJ                                                                                                                              HCS BQAF< of the e dti g                   ion of an Accident Involving craft in Sc}                                                                                                                   C                 rier 0 ^..ration4206---40Mrs. Virginia Gilcsby, a passengerJ                                     was slightly injured in an accident which occurred off Parrels Island,                                     Bermuda 5 British .rest Indies, on October 83, 1940 about'6:51 pm. LIST                                   The airctaft, a BaxuAmerinan Air- ways Sikorsky flying boat, Model S-42-B (UC 16735)                          , whs slightly damaged. In command of the flight was Captain J, B. Culbertson, who held a commercial pilot certificate with a Class 5 Rater rating and who had accumulated about  12,000 hours flying time. First Officer L C. Lindsey, who v/as properly certificated and appropriately rated, and five other members completed the crew, None of the crew or any of the other nine passengers was injured.The aircraft departed Baltimore, Maryland at 12:21'pm. 23T bn a ' regularly scheduled flight to Bermuda, with a crew of seven, tan passengers, express and baggage. The aircraft was loaded within its placarded . limits. The weather was excellent at the time of departure and throiig?-.out the trip. The flight proceeded without incident until about 4:35 tun, when the Captain received a radio message to the effect that the power boat equipped with a search light, which is normally used to aid aircraft in night landings, was out of commission and that a small boat which was not equipped with a search light would be used instead. The Captain, subsequently stated that, since it appeared that the fuel then on board was insufficient for a return to Baltimore, he decided to continue to Be ?muda. Shortly after- wards, he received the routing message relative to landing conditions                                                                                                                                                                                                     v>, sliow- ing the Kollsman setting as 30.02,                                                                                                                                        The Captain asked for a confirmation, since a message previously received                                                                                                                                       had given the setting as 30.22. The setting of 30,02 was confirmed                                                                                                                    me flight arrived over Bermuda at approximately 6:25 p.m                                                               EST, To assist the pilot in making night water landings there                                            eleven electric lights, pieced about 300 feet apart, are arranged in a straight line in the lending area,                                                                                                                                                                                   heading into and parallel ".with the                            prevailing wind direction. The light on the approach end is green, ' the n ext                           nine, white, and the last one red, The landing is made to the right, parallel with the lights,                                                                             The Captain circled the landing area during his descent,                            found the line, of lights properly placed into the wind, and received - a green flara from the launch                                                                                                indicating that the area'was clear of obstructions. At an altitude of                                                                                                                    approximately 500 feet, he lined the aircraft up with the lights for a final a                                                                                                                  proach and started a descent at a rate of 300 feet per minute and 90 knots indicated air speed, with                                                                                                                                                                                               full flans, then still well back of the first light end while it was evident that the nlane was well above the surface of the water, the Captain noted that the Kollsfiian. . registered about 10 feet. He slowed the rate of descent to about 100 feet per minute and his air speed to 75 knots, and ordered the landing lights timed on. He then.asked the First Officer the reading of his Kollsman and : was advised that it was minus 100 feet. A glance at the Captains vcoi From                             reading. Holding the same rate of descent and air -2 -<,neBd the Captain continued his landing procedure and at the seventh light the aircraft contacted the water going immediately into a water loop to the right. The Captain applied a hard left rudder end applied full throttle to the" No. 4 engine, but he did not succeed in stopping the aircraft until it had turned about 130 degrees. The plane was examined and precautions w0re taken for caring for the passengers. Upon finding that the damage was negligible, the Captain turned the aircraft around and taxied it to the Tegular dock            .                                                                    ; ?Subsequent investigation revealed that the conditions of the water and the wind at the time of this landing were not unusual. Following the landing, the true KollsJran reeding was ascertained to be 30.22. This difference of .20 from the radioed setting of 30.02 is approximately equivalent to 200. The error was on the safe (high) side; nevertheless the result was confusing to the pilot.PROBIE-UZ C.WSE;.later loop.CONTRIBUTING FACTORS: 1. Srroneous altimeter setting radioed to the approachingaircraft. 2.  Pilots error in judging altitude. u ad. *File No. 2980-41REPORT OF THE CIVIL AERONAUTICS BOARD of the Investigation of an Accident Involving Aircraft m Scheduled Air Carrier OperationMajor damage vrs received by a Model DC-3 Douglas aircraft in an accident which occurred about 8:45 a.m. (EST) on Junu 8, 1941, -t theLlopango Airport, San Salvador, Salvador. The plane, NC 25657, was owned and operated by Pan American Airways, Inc. The crew consisted of C^pt^in Samuel T. Peters and First Officer William. C. Carlton, both of whom were properly certificated and appropriately rated, a radio operator, and a steward. There wore twelve revenue passengers ^boird. None of the occupants was injured.The flight, designated by the carrier as No                                                                                                               501 of Juno 7, 1941, originated at Brownsville, Texas, with Port of Spun                                                                                                                 Trinidad, as its destination. Numurous intermediate stops wore s                                                                                               choduled, including Tampico, Mexico City, Guatemala City, nnd San Salvador,                                                                                                                             The aircraft departed Guatemala City for San S-lv^dor approximately on schedule,                                                                                                                               /ji th its total weight and weight distribution within the limits nr^senbed by tho Civil Aeronautics Administration. ^Author conditions over the route wore good. When tho aircraft was a few miles from Sm                                                                                                                               aIvador, a radio message was received givmo wcathor information th                                                                                                                                which included the f^ct that th                                                            wind was from the southwest and t velocity of about six to eight m.p.h.                                                            The contain elected to land from north to south and started his                                               pproach.                                         ibout two mil*. s from thv nortnern boundary                      of the airport h                                       obsurvud the              ) windsock which indie ted tht thu wind was                      still from the southwest.                                                   The    aircraft passed over thu northern boundary                      of the airport it :n                                                 ir speed of                about 80 m.p.h. First contactwith tho                      ground was me de at -*                                               point ?bout               780 foot from tho northern boundary of tho field                                             nd the aircraft                           bounced for               a distance of about 540 feet before                      gain making contact.                                                   Brakes wore               applied but they wore ineffective on the grass-covered runway which was ^ct                                                                                    from a recent rain. Tho aircraft continued ahc^d and ns it ncar-d the ~dgc                                                                                    of thu field, which was bordered by a ravine, the captain ^ttempt^d to ground loop,                                                                                                          Thu tail wheel W'S unlocked, and right brake and left throttle wore applied,                                                                                                                        Tnu groundloop had progressed through about 90 degrees and the                                                                                                  ircruft was traveling about 20 m.p.h. when tho                                                   loft wheal went over the edge of the ravine. The aircraft c on11nuod                                                  turning for about 90 degrees and then slid down tho ravine tail first.                                                   It came to rest -boat 50 fuot down the slop-. --- 2 --- File No. 2930-41It was subsequently -'sccrtnincd that th^rc h'd b^cn no malfunctioning of the mrcr-ft or any of its components, including the brakes. Tho subject rum-ray is 2490 feet long and the wind, nt the time of the landing, was 'bout six or eight m.p.li. from dircctii' about 45 degrees to the right of tho appro-'ch path. Since the accident, the earner has stopped tho use of the subject runwxvwhui : .rind of less then 12 m.p.h. exists.prob.'lBle cause. Action of pilot m continuing o landing aft-r overshooting ora short slmpcry lunw-y.BY THE BO.uD/s/ jj I.-i-i C.'.-rlec 3r-~iSccrer-ry Ells No. 51O5-U1REPORT OP THE CIVIL 21EROK.UTICS BO*J=D f theinvestigation of n Accident Involving Aircraft m Scheduled Air Carrier OperationAn accident 1 hich resulted m extensive damage to u. Seeing model Jin flying boat, KC 18601, o/med and operated by Pan ,neric>n Airways, Inc., occurrea ^t ^pra Harbor, Guam, about 11 00 p.m. G.C.T. on August 16, 1941  No injuries were                                               sustained bv any of the                                               29 revenue passengers,           the 16 non- revenue                      passengers                                          or the crew of 10             The crev included Captain Henry J * Chase, Comlot Edwin Davis Avary, end                                                                           Third Officer R. F. Brcrm, each ofwhom wc s properly certificated and appropriately rated. The other members of the crew were R. C. Campbell, Second Officer, R. N. Goodson, First Engineer, J. B. Parrish, Second Engineer, P. Wiliams, First Radio Officer, R. B. Hanley, Second Radio Officer, and Villiam Murray and A. Cnunco, Flight Stewards <,The flight, designated by Pan American Air^ys, me., Trip 517 513 s had originated at San Francisco ana was returning to th? t point from Singapore, a landing had been made at Guam, which one of several inter- mediate stops. Because of unfavorable take-off conditions, consisting of heavy swells in th- outer harbor, light wind (6 to 8 knots) end he^vy load (28 pounds less than the naximan permitted), the attempted txe-off from Guam was delayed about 2-1/2 hours Zhen the take-off s attempted, a run- \ ay m the inner harbor, protected from hCuvy swells, was used. This runway has a clear channel about 6030 fc-t Iona. Uncertain that ho could accom- plish the take-off in this distunes, C- ptcin Che-sc decided that unless he should become airborne befor^ reaching it, he would discontinue the attempt at e pre-selected point hero h? still would have adequate                                                                                           space to come to-> s-fe stop. Tho spot he chose for discontinuing th- tak--off vs s judged by buoy, the locution of vmrn was msint-rpr^ts-d because, unknown to Captain Chase, <- similar buoy v is Assent from its proper pl-.ee. This confusion m the channel markings led tho captain to prolong his take-off attempt 200 ytrds beyond tne intended point,                                                                                         and, m bringing his craft to a stop, the captain failed to clear t coral                                                                                       shoal i/hich d^m^ged tne bottom of the hullPROBABLE CAUSE.                                                Absence of s marker buoy from its proper pl.ee on the ma rk e d runwa v.BY THE BOARDSecretary See our selection of aviatioon documents at RareAviationfcom . Agojcoo 'by                                                               i.c > o File No. 1;929-U1HErOPT OF THE CI .'IL ^HOl^UTICS BO..HD ' of theInvestigation of an Accident Involving Aircraft m Scheduled Air Carrier OperationA no del S-h26 Sikorsky, NC 1537^., owned and operated by Pan American Airways, Inc., ?f Nev; York, received minor da nags in an accident which occurred about 5 35 Pri. on September 2J, 19tl, on Biscajue Bay, Miami, Florida. There '.ere no personal injuries. The occupants vrere 17 revenue passengers and a crew of 7, including Captain Francis Scott Key Levis and First Officer Lillie Griffin Reese, Jr., one flight mechanic, two radio operators, and tv/o flight stewards. Botr the captain and the first officer were properly certificated and appropri- ately rated.Pan American Airways FLignt No. of September 23, 19A1, originated at Barranquilla, Colombia, and was en route to Miami, Florida, with scheduled inter- mediate stops at Kingston, Jamaica, and Cienguegos, Cuba. As the flight ap- proached Miami it received a radio message from xhe companys ground station th.t the wind was north 5> and that there were two rain squalls in the vicinity, but the landing arcs was clear end smooth. The flight at that ti ic iT^s contact, ind a lending approcch was started toi ard thv mrth from on altitude of ^bout BOO feet. The carburetors wor^ - djustca to standard position for landing, the engines wore set at 2250 r.p.m. and 15 inches of manifold pressure. The flaps xerc extended to the 35-degrco position. Shortly after contact with the water had been made, and is th- u.ircr^ft "x -s decolor, ting, th- flaps i ora r< ised and the stabilizer ves placed in a nosc-ncavy position, the aircraft settled off the step, the right wing dropped, the right i mg pontoon struck th- v.tcr and the aircraft started t? turn to the ngnt. The pilot applied power to tne right outboard engine and succeeded in regaining control of the ship c-fter it hod made a turn estimated &t from I4.5    100 degrees. The companys landing launch was dispatched to the scene md the aircraft was led in and docked.Investigation disclosed that the aircrc ft vu s loaded belo* the authorized gross. 'Jhcre was no evidence that the aircraft vus landed in rn unduly nose-lovposition, vhich is conducive to v terlooping. It vas the c-p tains theory that a vmd shift, preceding the rain squall 1 hi ch hit the ship shortly after the lending was completed, caused the right .ng t-o dr~p just as the ship *as set- tling off the stop. On the other nand. Pan /mencen attributes the accident to the raising of tie flaps during the run on the step, causing a slight cnange of attitude and a momentary period of directional instability beyond the pov er of the rudder to c ranter*ct. As a result, the company has ordered the practice of raising the flaps during that stage of the landing discontinued. The damage was localized in tho right pontoon.PROBaBLE CaUSE FcilurO of the pilot to maintain control during deceleration c ftor contacting tho voter.BY THE HD.JW/s/ Dari^m Carries Brcrjn SecrotarySee our selection of aviatioon documents at RareAviation.com J                                       IAdopted                                    January 16, 1942 Released                                   January 16, 1942File No                   5106-41Docket No SA-50REPORT OF THE CIVIL AERONAUTICS BOARD Of the investigation of an accidentinvolving civil aircraft of the United States NC 15376 which occurred m San Juan Harbor, Puerto Rico, On October 3, 1941. CONDUCT OF INVESTIGATION An accident involving aircraft NC 15376, a Sikorsky S-42B, occurred during a landing m the harbor at San Juan, Puerto Rico, on October 3, 1941, about 5 48 p n (EST), while the aircraft was operating in scheduled air carrier service between Miami, Flordia, and San Juan, Puerto Rico, as Trip 203 of Pan American Airways, Inc 1/ The accident resulted m the destruction of the aircraft, fatal injuries to two passengers, serious injuries to two mem- bers of the crew, and minor injuries to four members of the crew and seven passengers The remaining passengers were not injured The Civil Aeronautics Board 2/ was apprised of the accident about an hour after it occurred Immediately after receiving this notification, the Board initiated an investiga- tion of the accident m accordance with the provisions of Section 702 (a)(2) of the Civil Aeronautics Act of 1938, as amended An investigator and an examiner were sent to the scene of the accident and arrived there about 1 00 p m , October 5, 1941 In accordance with instructions of the Board, the damaged aircraft had been placed under guard and the wreckage had not been disturbed except to the extent necessary to remove injured persons, cargo, and to conduct the subsequent salvage operations m removing the wreckage from the water Upon arrival, the investigator took custody of the wreckage and began his inspection After the inspection of all the parts of the aircraft was completed by the Board's per- sonnel on October 7, 1941, the aircraft was released to Pan American Public Hear ng In connection with the investigation of the accident a public hearing was held in Miami, Florida, on October 22, 1941 Robert W Chrisp, an attorney for the Board, acted as Presiding Examiner, and the following personnel of the Safety Bureau of the Board participat- ed in the hearing Frank E Caldwell, Chief, Investigation Division James H Douglas, Assistant to the Chief, Investigation Division, and Harold G Crowley, Accident Reports Consultant All of the evidence available to the Board at the time was presented at the hearing Eleven witnesses testified and fourteen exhibits were introduced Depositions of passengers on the airplane and other witnesses who saw the accident were received m evidence at the hearing While the Examiner and the representatives of the Safety Bureau were the only ones designated to ask questions directly of the witnesses, the Presiding Examiner, acting under instruction of the Board, announced at the opening of the hearing that any person who had any evidence, questions, or suggestions to present for consideration m the proceeding might submit them m writing to the Examiner No such questions were submitted during the hearing Upon the basis of all the evidence accumulated in the investigation and hearing, the Board now makes its report m accordance with the provisions of the Civil Aeronautics Act of 1938, as amended1/ Hereinafter referred to as ''Pan American" 2/ Hereinafter referred to as the "Board - 2IISUMMARY AND ANALYSIS OF EVIDENCE    1                               "   "''j        W---                'IAir CarrierPan American Airways, Inc > a Nev; York Corporation, was operating at the time of the accident as an air carrier under a currently effective certificate of public                                                                                                                                                                                                                                           convenience ana necessity and an air carrier operating certificate theretofore issued to it                                                                                                                                                                                                                                            pursuant to theAct These certificates authorized it to engage m air transportation with                                                                                                                                                                                                                                               respect to per- sons, property and mail between various points, including Miami, Florida,                                                                                                                                                                                                                                                Antilla, Cuba, Port au Prince, Haiti, San Pedro de Macons, Dominican Republic, San Juan,                                                                                                                                                                                                                                                    Puerto Rico,Port of Spam, Trinidad,                                                                                                   Bele:                       II                                                                                      Brazil, Rio de Janeiro, Brazil, Porto Alegro, Brazil, and Buenos Aires, Argentina.Flight PersonnelOn the flight under                                                                      discussion the crew consisted of Captain Charles A Lorber, First Officer Harvey E Breaux,                                                                       Flight Mechanic J. E Donnelley, Radio Operator W p Mahoney, andFlight Stewards Joe Catala and A E CalligariCaptain Lorber, aged                  45, had accumulated a total                                                                                of approximately 11,384 hours of fly- mg time and held airline                  transport pilot certificate                                                                                No 4554 with 4-M Land and 5                                                                   Land andWater ratings Since his                  employment by Pan American                                                                                 m 1928 he had accumulated a                                                                   total ofapproximately 1500 hours                   on Sikorsky S-42 airplanes                                                                                 and had had about 690 hours                                                                   of night flying He started piloting over the subject route in 1929 and subsequent to that                                                            date had flown on both the Atlantic and Pacific-routes of Pan American                                                            Since Captain Lorberrs re- turn to the Eastern                                                                                                                                               Division on January 16-, 1941, he -had made approximately six night land- mgs at San Juan m                                                                                                                                                 s' 42 airplanes His l-ast physical examination as required by the CivilAir Regulations was                                                                                                                                                  taken on May 6, 1941, and showed that he was m a satisfactory physical condition Captain                                                                                                                                                   Lorber had from time to time been given flight checks on various air- craft, including S-42's                                                                                                                                   His last flight check on an S-42 followed his transfer from the Atlantic Division to the Eastern Division                                                                                               This is in keeping with the policy of Pan Amen-can All pilots are checked when transferred from one- division to another                                                                  Captain Fatt, chief pilot in the Eastern Division, stated that in checking Captain Lorber on S-42Ts he had a tendency to            land with his nose down                                                                                                                                                   He further stated that this difficulty was pronip- tly corrected and            that Captain Lorber thereafter                                                                                                                                                          made several landings which were satisfac- tory and normal             Company records indicated that                                                                                                                                                          Lorber was a well qualified and proficient pilotFirst Officer Harvey E Breaux, aged 24, had                                                                                                                                       accumulated a total flying time of approx- imately 583 hours                                                                   He had been employed by Pan American for approximately six months prior to the accident                                                                     At the time of                                                                      the accident he held commercial pilot certificate No 61667 with a rating                                                                 of second pilot                                                                     His last physical                                                           examination as required by the Civil Air Regulations was                                                                 taken                               on August                                       4, 1941, and showed                                                         him to be m a satisfactory physical conditionFlight Mechanic J E                                                                                                     Donnelley had been employed                                                                                                                                  by Pan American for approximately 13 years and had flown as a                                                                                                flight mechanic for approximately 5000 hours                                                                                                                                              At the time of the accident he held a currently effective aircraft ana engine mechanic certificate issued by the Civil Aeronautics Administration - - 3 - Radio Operator VJ P Mahoney had been employed by Pan American for one year and eight months and had flown as a radio operator in aircraft for approximately 926 nours At the time of the accident he held a currently effective radio telegraph license, first class, issued by the Federal Communications Commission Mr Catala and Mr Calligari, flight stewards, had been employed by Pan American smce July 13, 1939, and April 16, 1941, respectively Thus, it appears from the evidence That Captain Lorber ana First Officer Breaax held the proper certificates of competency for the aircraft involved and were physically quali- fied The evidence further indicates tnat the remaining members of the crew were well qual- ified to perform their respective duties Airplane ana Equipment Aircraft NC 15376, a Sikorsky Model S-42B, was manufactured by the Sikorsky Aircraft Corporation of Bridgeport, Connecticut, and was purchased by Pan American m May, 1936 It was powered bj four Pratt ana Whitney SIEG engines and was equipped with Hamilton Standard constant speed propellers equipped with brakes At the time of the accident the aircraft had been flown a total of 7,832 hours and 9 minutes The airplane and its equipment naa been given a 100-hour inspection on September 29, 1941, and a pre-flight inspection prior to departure from Miami on October 3, 1941 The evidence shows that the engines and pro- pellers had been maintained properly and that none of the engines had exceeded the major overhaul period of 550 hours authorized m the maintenance competency letter issued by the Civil Aeronautics Admims trail on to Pan American This model aircraft and its equipment had been approved by the Civil Aeronautics Administration for air carrier operation over routes flown by Par. American for 32 passengers and a ere* of 6 It had been certificated for operation with a standard gross weight of 41,000 pounds 3/ The total weight cf the aircraft upon departure from San Pearo de Macons, Dominican Republic, the last stop before the accident, was 39,407 pounds which was 1,593 pounds less than its approved standard weight The center of gravity limits of the subject aircraft, as prescribed by the Civil Aeronautics Actainistraticn, are from 29 percent to 36 1 percent of the mean aerodymanic chord The aircraft was actually loaded so that its center of gravity was at 33 2 percent of the mean aerodynamic chord The condition of the airplane and the maintenance records produced by Pan American indicated that the airplane was ir. an airworthy condition when it was dispatched from Miami, Florida, on October 3, 1941, for the flight to San Juan, Puerto Rico History of the Flight Par American Airways, Inc , Trip 203 of October 3, 1941, originated at Miami, Florida, and was bound for Buenos Aires, Argentina, with numerous intermediate stops including those at Antilla Cuba, Pert au nrince, Haiti, San Pedro de Macons, Dominican Republic, and San Juan, Puerto Rico Tne trip was dispatched to San Juan, Puerto Rico, and departed Miami at 733am (BST), about 18 minutes after the scheduled time of departure Prior to departure from Miami, the flight cre/r, with the assistance of other company personnel, prepared a flight plan for the trip This flight plan was based on weather re- ports issued by tne United States Weather Bureau and Pan American weather observers for var-5/ The "standard weight of an aircraft is the maximum allowable gross load for landing ious points along rhe route The weather over the route, as far as San Juan, Puerto Rico, was good, except for anticipated head winds, and indicated contact flight                                                                                   San Juan is an overnight stop on Trip 203, the flight being continued the                                                                          following morning with a differ- ent aircraftThe flight proceeded uneventfully to Antilia, Cuba, where it arrived at 11 12 am (EST) (52 minutes late) and departed at 11 30 a m (EST) (50 minutes late) The landing and take-off were without incidentOn arrival at Port au Prince, Haiti, where a landing was effected at 1 43 p m (EST) (1 hour ard 3 minutes behind schedule) a slight swell was running on the surface of tie water As the aircraft decelerated and settled farther into the water the crew felt a shock on the aft end of the hull structure This shock was not severe, but, id accordance with Pan Americans custom, the captain ordered an inspection of the aircraft This was performed by First Officer Breaux and Flight Engineer Donnelley It consisted of a visual inspection of the aircrafts empennage and of the inside of the hull and revealed that no damage had been incurred Following this inspection and the transaction of routine loading and unload- ing at Port au Prince the flight was resumed at 2 11 p m                                                                      (EST) (1 hour and 11 minutes behind schedule)Trip 203 proceeded to San Pedro de Macons, Dominican Republic, where a normal landing was effected at 3 52 p m (EST) (1 hour and 17 minutes behind schedule) At 4 09 p m (EST) (1 hour and 19 minutes behind schedule) the flight departed for San Juan, Puerto Rico The aircraft carried 21 passengers, a crew of six, 985 pounds of baggage, 614 pounds of mail, 1225 pounds of express, 79 pounds of company mail and cargo, and 775 gallons of fuel This load, as previously stated, was under the allowable limits and was properly distributed with reference to the center of gravity of the aircraftThe flight plan for this leg of the flight called for contact flight at a cruising al- titude of 9000 feet with an estimated flight time of 1 hour and 40 minutes, indicating tine of arrival at San Juan as 5 49 p m                                                                   Official sunset was 5 23 p m               (EST) at San Juan                Thealternate destination was given                                                          as the point of departure, San Pedro de MacorisCaptain Lorber stated that the aircraft was flown at an altitude of about 8000 feet over most of the route and when the flight was about 60 miles out of San Juan he had descended to an altitude of about 7000 feet At this point the captain started a descent at a rate of about 400 feet a minute This procedure would place the aircraft, according to the captains estimate, at an altitude of about 1000 feet at the time it arrived at a point 15 minutes out of San Juan HarborTne radio log of the flight between San Pedro de                                                  Macoris ard San Juan, Puerto Rico, reveals                                      a number of contacts, all of which were routine and made by CW (telegraphic code) radio                                        The last routine contact was made at 5 30 p m (EST) and, as recorded, read as follows"NO 15376 at 5 30 p m signted the San Juan Airport                            The estimated time of arrival over the airport is 5 45 p m                  The altitude at 5 30 p m is 1000 feet and will be maintained until the aircraft is over the airport Signed --- Lorber This is                                         the customary "sighted message and indicates that the destination is m sight Immediately after this, the captain attempted to make voice contact with the ground station - - 5 - usirg a tAO-way radiotelephone recently installed fo^ short distance use between t*e air- craft m flight or afloat and the local ground station ard be stand-by landing launch This effor+ was unsuccessful because the apparatus was inoperative The snips operator tben called the land station m code, cn the aircraft's regula radio set, ana asked for the land- irg conditions The land station replied that he aid not have them The snips operator related that message to tbe captain and remarked that they should be octamed The ships operator the*" retuned his radio to /oice frequency and succeeded m hearing part of a con- versation between the landing launch and the ground station, m which was renticnea the fact that the ground operator had obtained the larding conditions The radio operator cn board the airplane then asked the ground operator, "How aboux it9" and was told to sxand by until they, the landing conditions, were checked The ships operator replied, "0 K , go ahead" The operator in charge of the lord starion then transmitted tre larding conditions, "Wind west 3 Sea sligbt Kollsinan 2992" Tbis message was filed at the Sen Juan radio sta- tion at 5 45 p m (EST) This message was not received by the aircraft Because it was just about to contact the Pater, and, m accordance with reguJar procedure, xhe operator had turned off the aircraft's radio Captain Lorber, during this time, had continued to aescend until the aircraft was at an altitude of about 500 foci at a point a few miles west of San Juan Harbor Ho tnen aligned the aircraft with a row of anchored reference landing lights m the harbor and started a final approach Mr Jahncke, xhe Relief Airport Manager, had ordered the crew on the landing launch to prepare equipment for a night landing a considerable period of time before darkness Seven reference landing lights were arranged m a line 2000 feet long from east to west and paral- lel with the wma A rea light was placed on the upwind er.a, a green light on the downwind end and the intermediate lights were white In using this system of lights as a landing refcrence, tre aircraft usually lands from the green light toward the red light and to the right side of the entire line so that rhe captain, who is seeted on the left side of the aircraft, will ha*ve the lights continually within ready visual reference Before the lights bad been arranged, the crew on the launch bad ascertained that there were no floating ob- stacles in the landing area After placing the lights tbe launcn stood by approximately abeam of the green light and about 300 feet north of it Tbe company procedure is to pro- ject the beam of the landing launchs searchlight in an upwind direction parallel to the row of landing lights so as to enable tne landing aircraft co land between the beam from its searchlight and the string of landing lights However, this was not done m this instance Decause the beam of the searchlight Aould have been directed toward the incoming aircraft since it was being brought in downwind and might well have blinded the pilot About five minutes after the lights nad been strung, the incoming plane was sighted from the launch Shortly afterwards a white flare was fired from the launch m accordance with regular procedure for the purpose of calling the attention of the aircrafts crew to the general locality of the lignts The radio oporator on the launch attempted on four differ- ent occasions after the aircraft was sighted to transmit landing conditions to it by radio- telephone but, as previously stated, these attempts were unsuccessful due to the failure of the aircraft's radiotelephone It is also customary to fire a green flare from the launch during the latter part of the aircraft's approach to indicate that the landing area is clear Ur Jahncke, m charge of the launch, stated that this was not done because it had not be- come comoletely dark Before beginning his f.nal approach, the captain elected to land in the direction in winch he was then approaching, i e , toward the east, the direction opposite to that whicn See our selection of aviatioon documents at RareAviation.com ---  ---6 a*was indicated oy tne colored lights He decided to land m this direction because ne had concluded from the absence of any significant drift of the smoke which was rising from num-erous fires around the harbors edge that the wind was negligible Captain Lorber stated that ne could see the green light at the far end of the string of landing lights Captain Lorber stated that he made his approach in the normal gliding attitude, at the usual speed and rate of descent He ordered the flight mechanic to put the carburetor mixture controls in the full rich position and this was done First Officer Breaux stated that during the final approach the air speed was about 80 knots (approximately 92 m p h ) At an altitude of about 400 feet, the flaps were extended fully When the aircraft had about 200 feet of altitude the propellers were put m low pitch The aircrafts landing lights were then turn- ed on The aircraft passed the red anchored landing light at an altitude estimated by the captain as 10 feet According to Captain Lorber, a brilliant moon, which was almost directly overhead, tended to reduce the usefullness of the aircrafts landing lights because it made them reveal the water surface less clearly About 20 or 30 percent of the 2000-foot landing strip, marked by lights, had been passed when the aircraft first made contact with the water at an air speed of about 82 m p h This was at approximately 5 48 p m (EST) The captain immediately closed the throttles The boat continued planing ahead for a short but undeter- mined period of time, possibly two or three seconds, when the captain observed that it was turning to the right He applied rudder control to tne left and then, noticing that this did not have the aesired corrective effect, applied power to both of the right engines This application of power also failed to arrest the turning and the aircraft continued to swerve as the nose dug increasingly into the water Cabin occupants were thrown violently forward and sidewise to the left against their safety belts The swerve to the right became violent and the left vang float struck the water About this time the aircrafts hull broke completely into two sections at a point approximately over the main step of the hull The location of this break was through that section of the hull where the forward passenger com- partment, D", joins the cargo compartment The two sections of the hull filled rapidly with water and sank to a depth of about 15 feet where they groundedThree small children, aged one, two, and three years, had been occupying Compartment D with their mother At the time of +he accident the largest child was sitting beside his mother, with his safety belt fastened 4/ The mother was holding one of the smaller children, while the flight steward was sitting on the opposite seat holding the other child On first contact with the water, both children who were being held were thrown violently from the arms of the mother and the steward 5/ Almost immediately after the hull of the airplane broke ir two at Compartment D, all of the passengers in the aircraft were thrown around violently m complete darkness Both the adults who were m Compartment                                                                        D were almost com- pletely submerged and were unable to find the two children whom they had                                                                    been holding The bodies of these children were subsequently recoveredCaptain Lorber and other crew members made every effort to direct                                                                              the rescue of all passengers The crew on the Pan American landing launch and other persons m the vicinity immediately rendered aid and all the occupants of the aircraft except the two small children referred to above were taken ashore Hospitalization was provided for those requiring i-4/ Prior to landing the sign requesting passengers to fasten their seat belts had been turn- ed on and the first steward ascertained that the passengers had complied 5/ After the occurrence of this accident, Pan American devised and put into use a harness arrangement by which a child m arms is secured to the body of the person holding the child.20494---5From PilotManuals.com / RareAviation.com Condition of the Wreckage Prior to the arrival of personnel of the Board and personnel connected with the Civil Aeronautics Administration, the wreckage had been salvaged by United States Navy and Pan American personnel It had been taken to the nearby Naval Air Station where it was readily accessible for examination Inspection disclosed that the hull had broken into two pieces just forward of the step The forward section of the hull exhibited considerable damage, especially on its left side, from bending and compression loads, such as would be caused by severe impact with the water It appeared that the bulk of the impact had been taken by the left portion of the bow A severe dent, apparently from compression loads, was found on the left top side of the bow about eight feet back The right side of the front section of the bow and the front portion of the keel remained generally intact The loft flap was broken off along a line of cleavage more or less coinciding with the hinge line, indicating that it had been down at the time of the accident The left wing tip pontoon was torn completely from the left wing, and was damaged in such a way as to indicate clearly that the impact loads were from the nose and the left side of this pontoon The left wing was broken completely away from the hull It was damaged m a manner suggesting that the direction of the water loads had been against the leading edge which was crushed backwards for a distance of about 70 percent of the span The right wing also was torn from the hull but was damaged much less than the left wing There appeared to have been much less water load on its leading edge The right wing tip pontoon remained attached to the wing and was not damaged severely Most of the empennage units were broken from their respective fastenings but this breakage appeared to have been incurred during the salvaging operations The control system in general was badly damaged as was to be expected because of the neavy loads imposed during impact and subsequent salvage It was, therefore, impossible to determine positively that the cortrol system was intact prior to impact However, the evidence indicated that the entire control system had remained fully operative until the time of the accident All four engines were subsequently tern down and inspected but no indication of power plant failure or interruption was disclosed The condition of the blades of the four pro- pellers, although some of them were bent during salvaging, indicated that little or no power vas being applied at the time they were submerged All four ignition switches were on The switch which operates the sign indicating that passengers should fasten their seat belts was on The landing light switches were on The flap control handle was m the "down" position and the flap indicator showed "full down" All mixture controls were m the full rich position The propeller pitch settings were found to be in various positions Numbers 1 and 4, the outboard left and right controls, respec- tively, were m "take-off" position, while Numbers 2 and 3, the inboard left and inboard right controls, respectively, were found to be about half-way between "take-off" and "cruise" positions The throttle positions were found as follows Number 1 half-way between the open and closed position. Number 2 m the fully closed position. Number 3 m the one-quarter open position, and Number 4 m the fully open position The positions of the throttle and propeller pitch controls, as ascertained subsequent to the accident, are not definitely indicative of their positions prior to the accident, their fore and aft travel making it possible for the strong accelerations in the aircraft during the crash to have changed them In addition to the parts of the aircraft the conditions of which have been aescribed above, all remaining component parts and all the instruments installed in the aircraft were thoroughly examined No failures during flight and no conditions which could have contribut- ed to the accident were revealed As stated before, the voice radio installed m the air- plane was inoperative during the final approach to San Juan                                                                 This radio equipment was sobadly damaged during or subsequent to the accident that                                                         it was impossible to determine why it did not functionA thorough inspection failed to disclose evidence of                  any appreciable amount of corrosion which might have contributed to the weakening of the general structure of the aircraftThe nature of the damage to the hull and wings indicated that it was the result of the aircrafts being subjected to severe water loads applied first against the lower left portion of the bow and then against the left wings leading edge, and that m the interval between these two impact loads the left wing tip pontoon was crushed and broken backwards and later- ally from the leftConduct of the FlightThe dispatching of the flight from Miami, Florida, to San Juan, Puerto Rico,                                                                          with three intermediate stops was m accordance with proper procedure The fact that the                                                                           flight was conducted at an altitude of 8000 feet over most of this leg of the route, rather than at the 9000 feet prescribed m the flight plan, is not pertinent to the accident, although it was forecast that the most advantageous winds would exist at the 9000-foot level San Pedro de Macons, the last port of departure, is not equipped for landing at night and according to company procedure, flights are not dispatched from that port later                                                                          than a time which will allow return and landing at that port during daylight, if mechanical                                                                        trouble or unfavorableweather is encountered before reaching a point half way to San Juan                                                                          The time of departure from San Pedro de Macons was                                                4 09 p :  II                (EST) This departure time, taking cognizance of the slight difference m times                                               of sunset               at San Pedro de Macons and San Juan, was consistent with the above procedureFlight 203 was scheduled          to arrive           at San Juan before sunset, but because it had left Miami 18 minutes late and had become increasingly so as it progressed because of head winds, it was apparent to the crew during the latter portion of the flight that a night landing would be necessary at San Juan HarborThis is consistent with proper procedure since night landings at San Juan Harbor with the type of equipment involved were allowed by the Pan Americans Operations Specifications, which are a part of the terms and conditions of the air carrier operating certificate issued to Pan American by the Administrator of Civil Aeronautics                                                           The harbor appears to be entirely suitable for night landings so long as the pilot involved is proficient 6/and Pan Americans system of lighting and patrolling the landing area is followedWeather conditions were favorable for operation over the portion of the route involved Investigation of all weather services disclosed that the forecast and other weather advice, made available to Captain Lorber, including the conditions of the water surface at all points of landing, were substantially accurate All weather observational facilities involved func- tioned m an entirely normal manner throughout the flight6/ Immediately after the accident the Administrator prohibited night landings at San Juan and other points on this route, pending the conclusion of this investigation and a demon stration by the pilots of their ability to make such landings We have concluded previously in this report that the aircraft involved m the accident had been properly maintained and was in airworthy condition when it took off from Miami, Florida An examination of the carrier's records shows that it had been given the required periodic checks and a pre-flight inspection prior to its departure from this point The possibility of damage to the aircraft during the landing at Port au Prince was thoroughly investigated by crew members at the time and no carnage was found The water surface at the time of this lancing was not unusual The waves were much too small to be of any importance and the swell estimated at less than one foot in height was not of sufficient magnitude to produce severe landing leads Moreover, all three of the flight officers testified that tne aircraft, engines and controls functioned normally during the remainder of the flight to San Juan, including the landing and take-off at San Pedro de Macons The fact that tne aircrafts radiotelephone was inoperative is not material for at most it is used only as an additional radio facility to the flight while operating m close prox- imity to a station The conventional (telegraphic) radio set was still available to Captain Lorber bad he desired to obtain landing instructions prior to landing Since Captain Lorber had knowledge of the wind conditions at the tine of his approach to San Juan and could see the landing lights laid out m the harbor, his failure to obtain landing instructions did not contribute to the accident The Board having concluded that Pan Americans facilities at San Juan are adequate for night water landing it is now laced with the question as to whether the crew on the landing launch at San Juan performed their assigned duties in a satisfactory manner The evidence indicates that they did Mr Jahncke, the Relief Airport Manager in charge of the landing launch, nad personally supervised the placing of the landing lights m the harbor In fact, all members of the crew of the launch were well qualified and performed their assigned cuties m a satisfactory manrer The lights were laid out properly with regard to the wind direction, and all were lighted The area adjacent to these lights which was entirely suitable for the larding, nad previously been scrutinized by the crew of the landing launch and found to be clear of obstructions According to company procedure the launch stood by after placing the lights approximately abeam of the green light and about 300 feet north of it The engine in the launch was kept running When it was determined that the airplane was approaching for a down- line landing, the search-light was turned m the opposite direction so that its beam would not impair the pilot's vision The white flare was fired from the launch ir accordance with regular procedure Although darkness had not become complete, the crew of the launch should have followed the regular procedure and fired a green flare, signifying "all clear" How- ever, the failure did not contribute to the accident since the pilot was not in any way mislead Immediately following the crash the launch proceeded at maximum speed to the scene of the accident and participated in rescuing the passengers and crew The rescue work was per- formed commendably Particularly noteworthy was the work of one Harold Roebuck, a native Puerto Rican who repeatedly dived and swam through the partially submerged cabin freeing passengers and removing them from the wreckage This action was attended by considerable hazard and physical discomfort as tne surface cf the water was covered with gasoline from the wreckage Next we must determine whether the conduct of the flight by Captain Lorber is m any /ay subject to criticism There appears to be no question as to the manner in which he io -operated the trip prior to arriving m the vicinity of San Juan He began his final approach without receiving landing instructions which appears to be contrary to Pan Americans estab- lished procedure While, as previously indicated, this failure clearly appears to have haa no bearing upon the subsequent accident, it constitutes an act of carelessness which cannot be condoned The failure of the pilots radiotelephone provides no excuse for this lapse since by delaying the landing for a few minutes, instructions could have been secured by the ships radio operatorCaptain Lorber landed downwind and                                             m a direction opposite to that indicated by the landing lights laid out by Pan Americans                                      ground crew There appears to be no justificationfor this violation of standard procedure                                       While landing a flying boat m the most convenient direction irrespective of the direction                                        of very light winds has generally been considered as a safe practice, Captain Lorbers action in this instance is subject to criticism because of the careful preparations which had been made by the ground crew for his landing The landing launch is carefully located with respect to the landing area lights in order that it can assist m marking the landing area by the beam of its search-light and m order that it can be as close as possible to tne point at which the airplane first makes contact with the water By landing m the wrong direction Captain Lorber made it impossible for the landing launch to perform these vitally important functions with maximum speed and efficiency At the time of the accident the wind was variable, although generally from a westerly direction, and of approximately 3 m p h velocityVarious passengers and both stewards, who were seated m different cabin compartments, testified that they were thrown violently against their safety belts This appeared to themto have occurred almost simultaneously with the landing The conclusion to be drawn is that this severe deceleration started at the time of, or very shortly after, initial contact with the water Such a deceleration occurring nearly simultaneously with first contact would have resulted from an extremely nose-low landing                                                       A preponderance of Testimony indicates that passengers were thrown violently sideways about the same time that they were thrown                                                           fo rward This is an extremely strong indication that the right swerve experienced by the                                                               aircraft also haa its origin simultaneously with or immediately following first contact                                                                with the water This, m turn, could be caused by, and leads to the conclusion that, the                                                                 aircraft was making some leeway, i e , side motion relative to the water, when it first contacted the water Although lay testimony is not often of primary importance particularly m cases in- volving so precise a maneuver as the night landing of a large flying boat, it appears that a quite accurate reconstruction of the accident can be accomplished from the testimony referred to above                 These cabin occupants were unable to see either directly ahead or directly down- ward and                 were therefore unable to            testify accurately regarding the attitude of the aircraft prior to                 the time of first contact                              However, their testimony as to events subsequent to the time of first contact, taking due                                              cognizance of the short interval elapsed, clearly estab- lishes the nature of the landing                                              The conclusion that must inevitably be drawn is that con- tact, severe longitudinal deceleration, and violent turning occurred almost simultaneouslySuch a set of conditions would result if first contact with the water was made                                                            while the aircraft was nose-down and moving laterally relative to the surface of the waterThis conclusion is supported by an analysis of the forces present during the                                                        landing of a marine aircraft We find that when the ship first contacts the water the point                                                     of initial contact is m the neighborhood of, or slightly ahead of, the step The step itself is locat- ed a short distance astern of the center of gravity In other words, the point of first contact, from which the initial retarding force acts, is in the neighborhood of the vertical projection of the center of gravity This means that there is little, or at most, a negli- gible tendency for rhe airplane to roxate or yaw'1 about the point at which the retarding force acts Directional stability on the water is neutral If the flying boat is landed m a tail-low attitude the po jn at which the water retarding forces act is definitely to the rear of the center of gravity This tends to provide positive directional stability If, on the other hand the flying boat is landed in a nose-down attitude, the decelerating force acts forward of the center of gravity tending toward directional instability unless control- ling forces are promptly applied Serious consequences may result if the airplane happens to be turning or if it has any leeway or side motion relative to the water We are forced to the conclusion, therefore, first, that the subject aircraft was landed in an unauly nose-low attitude, and second, that at the time of first contact while m that attitude, it was moving sideways relative to the water It appears from the record that there were no extraneous turning forces which might have been caused by non-uniform applica- tion of power or by faulty rudder tab setting Having arrived at this conclusion as to the manner m which the airplane struck the water, we must determine whether this resulted from faulty operation of the airplane by the pilot Captain Lorber testified that he was handling the throttles during the approach and landing at San Juan This duty is sometimes performed by the flight mechanic who handles the engines controls under the captains direction while some captains handle the throttles themselves This is a matter of personal preference varying with different captains The fact that Captain lorber handled the throttles himself appears to have no significance m this accident Captain Lorber, First Officer Breaux, and Flight Mechanic Donnelley testified that tne approach up to and including contact with the water was not abnormal as far as they could observe Captain Lorber testified tnat he retarded all four throttles immeaiaxeiy upon the air- craft's first contacting the water and that he did not subsequently apply any power except that whicb he applied to the two right-hand engines in an effort to arrest the swerve The CLef Pilot of the Eastern Division of Pan American, Captain Fatt, testified that the correct manner of handling the throttles during the landing of the subject type of aircraft consists m making the final approach with about 16 or 18 inches of manifold pressure with the engines turning at about 2250 r p m and continuing this condition for a period varying between 10 and 20 seconds after the aircraft first contacts the water Tbe purpose, according to Cap- tain Fatt m allowing the power so to continue was tc have enough control of the airplane to prevent the nose from oeing forced further into the water He states that the aircraft has this tendency and that a sudden cessation of power augments it Another reason that has oeen advanced m favor of maintaining the amount of power existing at the time of first con- tact js to make sure that the aircraft has made permanent contact with the water, rather than having touched the top of a swell, before the power is reduced According to other experts, the proper landing procedure consists of making the approach a th from 12 to 14 inches of manifold pressure ana about 2200 r p m and xhen in completely throttling the engine at the time of contact The landing maneuver is not subject to regular- ly established procedures m regard to throttle manipulation as tnat is affected oy many variables such as slight changes m attitude of the aircraft and condition of the water sur- face, as well as de loading and weight disposition of the aircraft, and, of course, the primary consideration, that of wind - 12Pan American's established procedure includes no specific directions as to throttle manipulation during landings of aircraft of this type By long-established custom the manner m which captains handle throttle controls during landings is left to their own individual judgment It is not believed that Captain Lorber's action m reducing the power to an idling condition at the time of contact can justifiably be criticized or that it contributed to the subsequent swerving of the aircraftHowever, it appears that Captain Lorber, through misjudgment, landed the airplane m an unduly nose-low attitude and while it was making some leeway The surface of the water ofSan Juan Harbor was slightly disturbed m some areas and glassy m others The existence of a glassy surface is frequently conducive to misjudgment of height above the water as well as, to a lesser extent, misjudgment regarding the attitude of the                                                       aircraft Another factor tend- mg to lessen depth perception was the presence of a bright                                                           11   oon nearly directly overhead This had the effect of illuminating the smooth surface of the                                                       harbor with sufficient light to decrease the effectiveness of the aircrafts landing lightsWith such a surface condition, a small amount of side motion of the aircraft relative to the water would be difficult for the flight crew to observe Although all known and re- ported winds were light, they were nevertheless of such strength and so related to the direc- tion in which the landing was being made as to have drifted                                             the airdraft somewhat to the leftThe procedure which Captain Lorber followed when the                                                    swerve started, m first applying rudder m the opposite direction and then applying power                                                 on the inside of the turn, is m accord with the best tecnniqueFollowing the accident, the action of Captain Lorber, as well as that of other crew members, m assisting and directing rescue operations, was exemplaryIIICONCLUSIONFindingsUpon all of the evidence available to the Board at this time, we                                                                             find that the facts relating to the accident involving aircraft of United States                                                           registry NO           15376, which occur- red at                          San Juan Harbor, Puerto Rico, on October 3, 1941, are                                  as follows1                                  The accident, which occurred at approximately 5 48                                p m (EST)               on October 3, 1941, to Pan                             Americans Trip 203 of that date, resulted m major damage to                                              aircraft NO 15376, fatal injuries to two passengers, serious injuries to two members of the                                                                     crew, and minor in- juries to seven passengers and four members of the crew2 At the time of the accident Pan American Airways, Inc , held a currently effective certificate of convenience and necessity and an air carrier operating certificate for the route involved3 Captain Lorber and First Officer Breaux were physically qualified and held proper certificates of competency to operate as air carrier pilots over the route involved - 134 Aircraft NG 15376 %as certificated as airworthy at the time of the accident5 Trip 203 was cleared _n accordance yitn proper procedure from Miami, Florida, to Sar juan, Puerto Hico, via Ant-Ila, Cuoa, Pori au Prince, Haiti and San Pedro de Macons, Dom- inican Republic6 At tne time of departure from Miami, Florida and at the time of the acciaent, tbe gross weight of the airplane did not exceed the permissible gross weight and the usable load *as properly distributed with reference to the location of the center of gravity7 At the time of departure from San Pearc ae Macons, Domm.can Republic, tne aircraft carried more than three times as much fuel as would normally be required, at cruising flight, to proceed to its next scheduled stop, San Juan San Podro ae Macons was the alternate port 7/8 Until tne time of the attempted landing at San Juan Harbor, Trip 203 had proceeded normally                                throughout its entire route except for becoming increasingly behind schedule9 Weather reports for San Juan had consistently indicated variable light wmas and gooa mailing and visibility This condition prevailed during the flight ano at the time of the landing.10   After arriving near San Juan, Captain Lorber began a contact approacn 11   The aircraft uic* not receive landing conditions transmitted over the radiotelephone because tne aircrafts voice apparatus was not functioning 12   Tne ground station's attempt to transmit, v*a CW, landing conditions to tne incom- ing aircraft was so Delated tnat the message was not received 13   Captain Lorber was flying the aircraft at the time of the acciaent 14   Aircraft NC 15376, its engines, and all of ns equipment, with the exception of the radiotelephone, were functioning normally until contact with the water 15   Following the approach NC 15376 contacted the water m an unduly nose-low attitude while moving sideways relative to the water 16   Almost immediately after first contact witt tne water the aircraft swervec violent- ly to the right and broke into several major sections PROBABLE CAUSE On the basis of tne foregoing findings and the entire recoro availaole to us at this time, we find that the prooable cause of the accident i^.-olvmg aircraft NC 15376 (Pan Amer- xca^s Trip 203) on October 3, 1941, was the failure of the captain to exercise requisite caution and skill in landing Tne smootn surface of t-e Aater which rendered difficult the captains depth perception as well as W evact determination of any lateral movement of t*e aircraft, constituted a substantial contrioutirg factor7/ ?>e subject flight was, curing its latter stage, actually without ar alternate as San Pedro de Macons is not equipped for night landings 14 -BY T*-E CIVIL AERONAUTICS BOARDZs/ George P Baker George F Baker/s/.Harllee Branch Harllee BranchZ s/-Edward.Warner Edward WarnerPogue,               Cha.rman, ard Ryan, Member, did not participate in the adoption of this report2Q494---5 File No. 1413-43Docket No* AC-4 Adopted: June 4, 1943 Released: June 13, 1943 REPORT OF THE CIVIL KRONAU TICS BOARD On the investigation of ?n accident invoPang aircraft of Uni bed States registry NC 14715 near Ukiah, California on January 21.1943 File I'o. Ih 13-43 Docket No. aC-4An accident, involving on aircraft of United States registry,NO 14715, a Martin M 1J0 flying boat, which was being operated byPan American Airways, Inc. in scheduled air carrier service betweenHonolulu, Territory of Hawaii and San Francisco, California occurred in Latitude J994fU, Longitude 12317'W (about 7 miles SSW of Ukiah,California), elevation approxinjjatoly^250 feet, at about 7:30 a.m. 1/ (PWT) , on January 21, 1943* ^hc flight was identified by the aircarrier as Trip No. 62100 of January 21, 1943 and was further identi-fied for purposes of communications as Flight V-1104. The aircraftwas completely destroyed by impact and subsequent fire.                                                                                                              The ninemembers                                                                       of the        crow and ten passengers                          were fatally injured.CONDUCT OF INVESTIGATION I 111.1110111 l---W I0 The Santa Monica Office of the Civil Aeronautics Board (hereinafterreferred to as the Boird) received notification at 10:00 p.m., on Saturday,January JO, that the wreckage had been located and the Board immediatelyinitiated an investigation in accordance with the                                                                                                     provisions of Section 2/ 702 (a) (2) of the Civil Aeronautics Act of 1938,                                                                                                      as amended. Air safetyinvestigators of the Board proceeded to the scene of the accident immediatelyand arrived there about 5:00 p.n, on January JI.                                                                                                      The wreckage of the air-liner had been placed under United States Army guard and was so kept untila complete examination had been made by investigators of the Board.1/                              All times referred to herein arc Pacific War Timo unless otherwisespecified. Sectjor 702 (a)(2) provides that it shall be the duty of the Board to Investigate such accidents and report to the Authority the facts, con- ditions, and circumstances                                                      relating to er ch accident and the probablcause thereof.From PilotManuals.com / RareAviation.com See our selection of aviatioon documents at RareAviation.com Hearing In connection with the investigation a private^ hearing was held in Son Froncisco, California, February 8 and 9, 1943* Allen P. Bourdon, Chief, Investigation Division, Safety Bureru of I the Board, was presiding officer and the following personnel of the Safety Bureau participated in the heonng: John M. Chamberlain, Assistant Director of the Safety Bureau; Senior iiir Safety Investigator Ralph r-. Seed; and Air Safety Investigator A. E. Cobjna. Upon the basis of all the evidence accumulated during the investiga- tion, the Board row makes its report m accordance with the provisions of the Civil Aeronautics - ct of 19J8, as amended. SUMLJPY AFP t.^LYSIS OF EAIDE',CE Air Carrier At the time of the accident Pan American Airways, Inc. (hereinafter referred to as Pon American), a Now York corporation, was operating es an < air carrier under a certificate cf public convenience and necessity and an air carrier operating certificate, both issued pursuant to the Civil Aero- nautics 2xct of 19J8, S amended. These certificates authorized it to engage m wir transportation with 1 aspect to persons, property and mail between various points, including Honolulu, Hawaii r-nd San Francisco, California. Flight Personnel The crew cf V-IIOI4. consisted of Robert a. Elzey, Captain, Orvcn K. Judd, First Officer, G. F. Aabcl, Pilot, John Haynard, Aavigavor, C. Pe Thompson, First Radio Officer, G. Vn. Angus, Second Radio Officer, John Hill, Flight Steward, L. A. Kuckota, First Engineer Officer, and J. J. Egan, * Second Engineer Officer.3/ Private hearings arc held .Aicn, for reasons of Notional security, public hearings arc inadvisable. Captain Elzey, aged 36, wr>s graduated from Temple University in 1929in Aeronautical Engineering. Ho later graduated ^rom the Naval Air Station,Pensacolo, Florida, where he accumulated 200 hours of flight training, 35hours on tnn-engmed boat                                                                              in petrol squadron, and over 600 hours as aflight instructor                                                         He also flew about 250 hours at various other NavalReserve bases. Up                                              to                      January 11+,- 1943# be had- accumulated approximately4941 flying hours,                                             of                      which 3359 were v/hilc in the employ of Pan -American.He entered the employ                                                                  of Pan American on November JO, 193&# and had servedin their Eastern, South American, Atlantic and Trans-Pacific Divisions                                                                         . Heheld an airline transport pilot certificate with 420-7200 h.p. multi-engineseaplane ratings,                                          as well as a radio telegraph certificate, second clasHis last physical                                          examination, required by the Civil Air Regulations, wascompleted January                                          11, 1943  Since his assignment to the Trans-Pacific Divi-sion, Flzcy had completed five trips from San Francasco to Honolulu, fourtrips from Honolulu to San Francisco, and two round trips to Auckland, HewZealand.First Officer Judd, aged 23, hold a commercial pilot certificate withsingle-engine land 0-80 h.p., instrument and flight instructor ratings. Healso held a restricted radio telephone certificate. He had completed fivecourses                     of the Civilian Pilot Training Program, including primary, secondarystudent              instructor, cross-country and commercial refresher. In CPT GroundSchool,                     he had covered navigation, meteorology, engine and aircraft construction, and maintenance                                                                                   last physical examination, required by theCivil Air Regulations, was completed March 24#                                                                                         As first officer, hehad completed 21 trips from Son Francisco to Honolulu, and 20 trips fromHonolulu to San Francisco# He had accumulated approximately 694 solo hoursas of January 14> 194-3 His flight time before he was employed by PanAmerican, on November 3> 1941, was about 240 hours. ~ 4  Jonn R. Maynard, aged 28, graduated from the University of Washington, Seattle, completed a navigation course at night school and had bad practical navigation experience on cruises during the summer while attending the University. He had completed five trips from'San Francisco to Honolulu and four trios from Honolulu to San Francisco. He was employed by Pan American on August 12, 1942, and was listed on Operation Specifications as Second Officer (navigator) on December 21, 1942. All of the balance of the crew vrere properly certificated, were physically qualified and, by reason of their training and experience, were qualified for the flight and equmment involved. The Aircra_ft The aircraft, NO 14715, ttos c Martin 130, A-cngine flying boat, Serial No. 557, and had been flown a total of 14,628 hours and 5 minutes. It -/as z manufactured by Glenn L. Martin Aircraft Corporation and was purchased ty the registered owner, Pan American, on November 14, 1935. It had been flown 1980 hours and 46 minutes since the last major overhaul and was last inspected on January 20, 1943. Numerous modifications from the original design had been reported to the CAA cy means of Repair and Alteration forms. The weight at the tine of take-off from Honolulu was the maximum authorized weight of 52,203 pounds. The aircraft was equipped with 4 Pratt and Lhitney S2a5G engines, each of which had been operated 37 hours and 23 minutes since the lost major overhaul, and 4 Hamilton Standard hydroma tic 3-oladed propellers. Hl^torv of the fii'-ht                 -                                     I Flight V-1104 departed from Pearl Harbor at 0030 Groeiurtch Civil Time on January 21 (5:30 p.m., PUT, January 20) nth its estimated arrival time at Sail Piancisco as 1718 GOT the same date (10:18 a.m. P.7T.) The dispatch of the flight from Honolulu was in order end according to sound operatingpractices, both as to the mechanical condition of th^ aircraft, engines, radio^and navigation equipment, and weather reports which outlined conditions knownand anticipated. The progress of the flight was entirely normal, and two-wayradio contact by CW                                                                          zas naintair_ed vzith the Island and the Mainland until1050 GCT (J:JO                                                                          B"rT). At about 1235 OCT (5:35 a.m. FWT) Pan AmericanFlight Hatch Office                                                                     at Treasure Island, San Francisco, received a message fromV-110U giving its due time at San Francisco as 1J55 &CT (6:J5 a.mt P^T), whichwas about hours ahead of the previously estimated arrival time of theflight.Satisfactory two-way radio telephone communication between V-IIOI4. andPan American, at Treasure Island, San Francisco was established about 6:16anu and at 6:18 am V-1102| corrected the estimated arrival time to 7*10 a mAt 6:22 am Treasure Island gave the flight a surface weather report asfollows: "Heather, heavy rain, wind south, force 1|4 to 1|.8, ceiling 900-1000visibility 1 mile to 2 miles, Koi] sman 999 millibars                                                                                We feel that San Diegois the only possibility unless it would be possible to                                                                               hold until after day-light Landing conditions are such you could not land                                                                                before daylightTreasure Island then asked V-IlOlj. again, "How do you feel about San Diego?Impossible to land here before daylight," The flight acknowledged thomessage                                             with, "Roger, thank you." Treasure Island asked again, "Will yougive us                                             what you night intend to do as quickly as you have decided Gohead"                                                 The flight answered, "Roger, we will let you know as soon as wcdecide.                                                 Standing by. Lotcr V-llOU asked Treasure Island, "If wo sot arounduntil daylight, how will our surface conditions be then. Go ahead." TreasureIsland then gave the flight the anticipated surface report for 9:00 a.m. "ForthBay, weather, light rain, wind southwest, force variable, ceiling 900-1000 See our selection of aviatioon documents at RareAviation.com - 6 - visibility 2 miles* thau is* anticipated for 9:00 a.m. The mes-'a^e was acknowledged by the flight. At 6:32* Treasure Islrnd fave the flight a position report as "Latitude 37.29 north* Lonjitude 123.49 west and asked them to confirm this oosition. Before this nosition A                                      V was confirmed* Treasure Island sent then a nev- position report at 6:50 a.m.* llWe have a nevz position on you - a new plot - you arc now m Latitude 37.30 north* Lon^tude 123.22 vreot." The report of this position* which "ould be cpproximately 43 nautical miles vrest^southvest of San Francisco* was acknowledged by the flipnt. The flipht next re- ported itself as over the Farallene Islands (about 25 nautical miles west of Son Francisco) c-t ?n altitude of about 5000 feet* and proceed- ing to the vicinity of KPO transzattinf station in S^n Francisco. At about 7:15 ".m. V-1104 advised Treasure Island that the flight had "been ever the area but --- now baking a course due west.11 Treasure Island confirmed this message by saying, "Fan American Treasure Island back, you are nou takm^ a course due wesu, you are taking a course due rrsst uo sea. Is that correct Go ehood." 7-1104 ans.'ered, "Thau's correct." Treasure Island uhon queried the flight regarding their altitude and flying conditions, uo hich V-1104 ansrered, "Flying conditions very poor, ro'iuired change of altitude to 7000 fest." Treasure Island con- firmed the message, signed of-f, and called the A.'-rrmy Traffic Control Station at Oakland so tat Oakland coo Id -rork V-1104. Upon hearing this call, estimated to have been made st 7:20 a,m., 7-1104 calledTreasure Island back and stated, "'^e are not interested in setting up on Oakland quite yet.                                           Yre would like to have a fix, please,                                                  so wouldyou arrange that? Go ahead." This was the last message received from V-1104. Treasure Island then checked with the Pan American launch,which was standing by in the North Bay awaiting                                                                                 the arrival of V-1104.At 7:26 a.m., Treasure Island attempted to contact V-1104, presumably to give them their requested fix. Evidence indicates tnat communicationbetween plane and ground uas satisfactory, despite periods of heavyram static.For the next twelve hours Treasure Island,                                                                                     KPO, CAA, and otherradio stations employing both CW and telephone,                                                                                 attempted to contactV-1104 but the flight was not heard from again.                                                                                       Heather reports tothe flight were sent "blind" by OT and telephone until after 6tOO p.nwhen officials ere satisfied that V-1104 could not be still aloft.Anticipating stormy weather m the vicinity of San Francisco andmaking provisions for the possible necessity of having to use San Diegoas an alternative destination,                                                                              the flight was fueled at Honolulu for anestimated 24.2 flying hours. Due to the favorable tailwinds ddring thelast half of the route, the flight had proceeded only about an evenfourteen hours up to the tine of the                                                                                accident (7:30 a.m.)        leaving fuelfor at least an additional ten hours of flying tine, or until about 5:00 p.n.Captain Elzey was avzare of this and, m all probability, had con-sidered San Diego as an                                                                                  alternate but intended to hold in the vicinityof San Francisco in the                                            belief that the weather would improve                                                     there around9:00 a.m.                                      and if it did not,                       he still had ample fuel to proceed to SanDiego. - 8 - Search and Discovery of the Wreckage Around 10:00 a.m. Pen American notified the Civil Aeronautics Ad- ministration and the Western Sua Frontier of the circumstances surround- ing the flight, and in the afternoon of the same cay the Commander of tne Western Sea Frontier notified Pan American that they would take charge of the search for the missing aircraft. Ground and air searching parties, made up of units from the Army and Navy and Pan American employees, instituted an immediate search. The search continued intensively until the late afternoon of January 30 when a Pan American captain, W. K. Price, searching m the Clear Lake area, advised by rsdio thvt he had located the wreckage. Naval searcnmg parties, a United States Amy detachment and Pan American officials arrived at the wreckage early Sunday morning, January 31. The scene was at an elevation of approximately 2500 feet just below a mountain ridge and about 7 miles SSW of Ukiah, approximately 90 miles north of San Francisco and about 22 miles east (inland) from the Pacific coast line. Examination of the Wreckage The condition of the wreckage offered little evidence of value ex- cept that the aircraft had sheared c number of small trees in its path about 75 feet immediately before impact, establishing that the aircraft had struck the ground on a dovmsi a rd angle estimated at approximately 10 headed in a northerly direction. The instruments were in such a completely demolished and shattered condition tnat examination revealed little or no reliable information. Ono radio receiver was found tuned inthe general band for "telephone" broadcast. Both the master and the IQindividual ignition switch ?s wore m the normal "on" positions. The automatic pilot control its m the "off" position. All four propellers,while badly damaged, indicated that porwr was being applied at the time of impact. The major mention cf the wreckage and the bodies of the victims had been subjected to fire which followed impact. Radio Aids Pwi American's Assistant Comnunicacions Superintendent testified <1 that the el'ctric power in th? vicinity of San Francisco, while it did not fail, bvgen to fluctuate at about 7:07 a.n. end the voltage dropped from 220 volts to 290 volts. He rtaued th_t his receivers did continue to operate satisfactorily and he believ-s that they transmitted hiossacws during that period. ?'o stated further, "There were other power fa-ilur-Es cn broadcast stations vrhich th- captain right h-iv- b~en using at uik came. Tm Chic Fngmcer of the Nationij Broadcasting Company m San Francisco informed us that KbO vent off thu 2j.r at 1/12 OCT (7:12 a.m. P'.T) "41cnnc was operating on has normal power of 50 kilowatts and resumed operation at 1414 GOT (7:14 a.n. F;iT) on r.duetd pomr of 10 kilowatts. The broed-castmg station at                                      Llontvrey,      KDON, "went off the        air at 1416           (7:16 ".m.FrT) and came beck on at 1442 ( 7:42 e.m. P'.T)                                                         * Also, I understandtint thk, Oakland radio vias off the air from 403                                                  (7:03 e.m. PVT) until1406 GOT (7:06 a.m. E.T)," Ho stated that the Superintendent ofIn ght houses                     m S<.n Franciscc informed Pan American that the Marine radiobeacons operated Formally and were not affected by any pow^r failures.Although slight interruptions were found to hove occurred m theoperation of eth^r radio aide to navigation within a roidius of severalmiles of San Francisco, none  as considered particularly significant - 10 - view of the fact that.KPO and the radio range station at Oakland are the facilities normally used by Pan American flights m the Bay area. Inasmuch as th^ only interruption to service from the Oakland range occurred prior to 7:06 a.nu, and the interruption at KPO occurred prior to 7:14 a.m., the feet that the last transmission from the plane gave no hint of difficulty yrith radio aids and u-as received at approximately 7:20 a.m., uould seen to indicate that such interruptions ^rc of no real consequence to th? flignt. * * 7/cather The Pan American flight was advised before departure from Honolulu that on reaching the coast at San Francisco moderate to moderate int..r- mitt.nt rain, with ceiling 1000 and wind S.7 24 knots, would be expected. A revised forecast was radioed to the flight cn route at 4:30 a.m., giving an expected frontal passage in the San Francisco ar a nt about 0:00 a.m., follo-rcd by wind SSJ 40 knots, ceiling 1000 feet, visibility 3 miles, ;nd intermittent rain. The following weather observations were filed by the Wcj ther Bur.au on January 21, 1943: 6:30 a.m. San Francisco Airport, instrument; ceiling 1200 feat, overcast, visibility l-j miles, light rain and .wavy ram squalls; sea level barometric pressure 998.3, temperature 57, de" point 55, .and StT 40, strong gusts, altmct-r siting 29.47. Oakland, contact; exiling 1100, overcast, light rain; sea level barometric pressure 999.3, temperatur. 55, daw point 53, wind SSE 26, altimeter setting 29.50. 7:30 a.m. San Francisco, instrument; ceiling 1000 feet, ovorccst, visibility 2 miles,light rain, heavy rain squalls; sea level barometric pressure 997.3,temperature 58, dew point 57, wind SSI 45, strong gusts, altimeter sot-ting 29.44.Oakland, contact; ceiling 1100 fert, overcast, light rain; sea levelbarometric pressure 998.6,                         temperature 56, dew point 54, wind SSE 32,altimeter setting 29.48.On the morning of January 21, an intense low pressure area* wascentered a short distance off the coast of tne extremely northern partof California and southern Oregon, with a warm front extending southwardoff the coast and a cold front extending south;/estward into the Pacific.Although the center of this low pressure area reached the coast con-siderably north of the San Francisco Bay region, the maximum severity of tnc storm appears to nave entered m the general vicinity of the Bayregion. Due to the steep pressure gradients, the winds -were vary strong aloft, and lo,.r ceilings existed ranging from about 1000 feet to as low as400 foot, with heavy ram squalls. The wind on the surface was also quitestrong, ranging mostly from 30 to 45 m.p.h. with strong gusts, from thesouth-southwest, making landing on water quite hazardous.                                     Due to cloudsand storm conditions, actual measurement                           of winds aloft was not possible.However,            it appears that southwest winds          prevailed        aloft ;n.th probablevelocities ranging from about 80 m.p.h                         at 3000 feet, to as high as 100 ormorx m.p.h. at 10,000 feet in the Bay district. It appears that the velo- cities would have been somewhat less m the region of Ukiah, probablyranging from about 64 m.p.h. nt 3000, to about 82 m.p.h. at 10,000. As the air mass involved was quite warn, icing did not appear likely below - 12 - 10,000 feet until after the accident had occurred. Considerable tur- bulence vrould havv prevailed up to 2000 or 3C00 feet above the surface duo to the strong winds. This would be particularly true over the more mountainous terrain. Otherwise no very great amount of turbulence was indicated, except that some increase would be expected up to quite high elevations at the time of the cold front passage. After the passage of the front, and later a trough Imo behind the front, cooler air moved into the area and the- icing level lowered to probably the neighborhood of 7000 feet. The warm front passed inland over the Bay region near 5:30 a.m., and was followed by the cold front at approximately 7:00 a.m. However, the change m air mass with the pas- sage of those fronts was slight and the situation aloft did not greatly change until later when colder oir followed the passage of a trough line inland. Only one front, viz., an occlusion, passed inland to the north ci the San Francisco Bay area, and the two fronts that passed over San Francisco became occluded before proceeding but a short distance inland. Foilwing the course of the flight across the Pacific, it would be expected that it would have first encountered northwesterly winds when coming into the influence of the storm area, followed by westerly, and finally southwesterly winds n^ar the California coast. In view of the fact that the intensity of this storm had not been realized, the strength cf the winds would not have been anticipated. It appears very probable that, due to these wind conditions, the plane was carried a considerable distance north of whore the captain expected to be after reaching the Califor-nia coast. Witnesses  Depositions secured from three persons, whc observed Flight V-1104 at different points from the ground between 7:15 end 7:30 c.r., agreed trot the cngini s seemed tc be functioning no ma Uy ^nd that the plane appeared to be flying just above the trees. One seated that th. flight wes headed north, another that it was m a course north-nortnwjst, and tic third, and probably the last on-.. to observe thu aircraft before its destruction, estimated its course as north-northcast era stated, "It SL.enk.d tc be coming do.m in the valley." All witnesses stated the plane r was flying v-ry lew, one stating, "It was very low, in fact it -was so low Iwcs alarmed cv~r the possibility of ths plane hitting the tre<s near the I nuuse." The witnesses lived m Mcdocirc Ccurty at distances varying from 3 to 11 miles from the scene of the accident. The last witness referred X tc above lives apprcxina.br ly 4 miles cast and slightly north of Boonville and tho wreckage was found approximately 3 lilcs north of her homo. It see^s apparent, therefor', fro... tK vltnesscs who observed the aircraft just prior to the impact and from pir^on-s who examnoa the wreckage, that the flight was oxocceding m a j^norul ncrtLi.rly direction at thu tire of the acrid.,nt. Captain Elzey had notif3 cd Treasure Island that he had "been over tho area out - - now taking a course due west." 4ccording oc tho testimony of tp Pan American's chi. I pilot for this division tins w-uld probably near, a westerly magnetic heading, or 270?, which when corrected for the variation of 18 east would result in a true heading of 288"'. This, together with th extremely strong south-southwest wind, estimated by the U.S. Alnther Bureau to have boon between 60 and 80 jn.p.h. at altitudes of from 3000 to 7000 feet3 would make it quite evident that he vas actually proceeding on a track closer to 350. If this xras the case, and the evidence so indi- cates, the flight xras actually traveling m a direction mere nearly north than .rest. All xu-tnesses agreed that there x/as an unusually severe xrind and rain storm in progress. All testified that they could see the blurred outline of a very large airplane but could not identify it. Its navigation lights were observed by all witnesses. Another airplane left Honolulu on January 21, at 0538 GOT and arrived over San Francisco at 10:13 a.m. P"T, about 2-3/4 hours after the subject accident. By that time, the storm had abated soruxrhat. The pilot of this plane testified that he let down from 9,000 feet through the overcast to 500 feet but being unable to get contact ho returned to 3,500 foot and by using the radio compass homed on the Mills Held Radio Range. He pro- ceeded over the range, homed on Oakland and let down on the southwest log of the Oakland range to about 1500 feet xhen X observed the .rater m San Francisco Bay. He then proce ded to his destination and landed. He reported the ceiling at that time to have be_n around 1000 fo ,t, visi- bility about 1 to 3 miles. He stated that at 1000 feet the air xras very rough and there xras a very strong south xdnd but that he encountered no icing conditions at any tune. CONCLUSIONS Findings 1. The accident, involving Pan American Trip No. 62100, of January 21, further identified as Flight V-1104, and resulting in fatal injuries to all persons aboard (nine crew and ten passengers), occurred approximately 7 miles SSW of U^mh, California st about 7:30 a.n                                                 (P7T) on January 21,1943- The aircraft vis completely destroyed by irmact and fire.2. At tin time of tii_ accident Pan Americ m held a certificate ofpublic convenience and necessity and an air carrier                                               operating certificateauthorising it to conduct the flight                                       Both certificates wore currentlyeffective.3.  Captain Elscy, First Officer Judd, navigator Jjfaynard, Radio Officer I Thompson and the remainder cf the craw mere physically qualified and held, certificates authorising chon to perform their duties on tno subject flight. 4.  The aircraft, KO 14715, <"s currently certificated os airworthyat the time of the < ccidcnt.5. Pan African's Trip Pa                                               62100, of January 21, originated atHonolulu, Hau'.ix with San Francisco, California as its final destination. It departed fron Honolulu at 0030 GOT (5:30 p.n. FJT, January 20), havingbuen clashed in accordance -nth company procedure to Son Francisco. 6.  The operation of the trip was normal until its reported arrival ever the Farallon-- Islands in the San Fr. ncisc"> aica at 6:50 a.m. at an altitude cf about 5000 foot end was prevented from landing at San Francisco by darkness and an unusu J ly severe wind and ram storm wnich resulted in poor Sea conditions. 7.  Satisfactory tw^-woy radio telephone communication between the flight and Pan Arncricon Traffic Control Office at Treasure Island, San Francisco had Leu in progress fron 6:16 a.n. to about 7:20 a.m. when rhe la^t message was received fron the flight. 8.  Khilo proceeding in the overcast awaiting uoylight and none JF favorable surface conditions, th- aircraft, under power and m controlled - 16 - flight, crashed in mountainous terrain at an elevation cf about 25CO f^et. 9. There was no evidence of failure cf any part cf the aircraft, prior to impact. 10.  The flight was advised by Pan American Traffic Control that San Diego was suitable for an alternate ccstmation and th^t .t other forecasts . indicated a landing would be possible ^t San Francisco ct abcut 9:00 a.n. 11.  Captain Elzey was aworo that he had sufficient fuel to remain aloft for aocut 10 hours after having arrived ov^r the Bay area and, there- fore, knevz he could remain m the vicinity cf San Francisco until at least 9:00 a.m. for mere favorable landing conditions befarc deciding whether nr not to proceed to San Diego. 12.  The evidence indicates that the pilot did not accurately fix his position at the time of entering tho San Francisco Bay area or at any time thereafter. 13.  The lact that at 7:15 <?.n. Captain Elzey reported having been ov-_r the area, and proceeding due west to s_a, indicates that at the time of the accident he believed ho was cv^r the cc^on and, therefore, free to descend to a lower altitude. 14.  Due t~< the unusually high velocity cf the scuth-s^uthwest wind, the flight, instead of being ov^r tnc ocean, was carried a considerable distance farther northward and eastward than the pilot anticipated or realized. 15.  There is definite evidence that the flight was proceeding north by yrest ovjr the mountains approximately 90 mlcs nrrth and slightly rest of its base at Treasure Island and :bout 22 miles cost (inland) of the c-ast Imo wncn the accident occurred. - 17Due consideration has been given to all possible factors whichmight have forced the flight to descent;                                                                   such as carburetor ice, imngice, power plant failure, structural failure, etc., but there was no evidence to indicate tne existence of any of these, rd th the possibleexception of carburetor ice. He.ever, Pan American has had extensive experience with this model aircraft and substantiated the fact that they had always been able to control any carburetor icing condition heretofore encountered with this model. Furthermore, the atmospheric conditions existing m the area at the time were not of such severitythat unusual carburetor                                      icing conditions would have been expected*The fact that during the lost                                                             11 miles of flight the aircraft -'ras quiteobviously in controlled level                                             flight further tends to substantiate this fact.                         Neither was there                      evidence to indicate that the pilot hadvoluntarily descended from his lost reported altitude of 7000 feetalthough it was stated by the operator that had he chosen so to do, he would net necessarily hava reported the fact immediately tc TreasureIslind. That the captain had not accurately fixed his position as being over 'die mountains seems clearlv indicated bv the fact that rfhether the descent was forced or voluntary, he would not knowingly have continued on the same course at such a loir altitude.PROBABLE CAUSE: Failure of the captain to determine Ins positionaccurately before descending to a dangerously low altitude under extreme Iv poor c at her conditions  during the hcurs of darkness. /- 18 -RECOLSODATIONS: 1. That a radio marker or facility be installed on the Farallone Islands or some equally suitable lo- cation to bk, used as an inner marker for all aircraft entering the San Francisco Airway Traffic Control zone from the Pacific. 2. That Pan American establish specific holding procedures for flignts in the Bay area whan landings arc delayed on account of iroather. APPROVED:/s/ L Welch Po,"io I. Welch Pojuc/s/ Harllec Eranch HarllOv Branch/s/ Josh Log J                          Josh LocWarner and Ryon, LLonbors of tho Board* dad nob take part m thedecision^ file No. 2143-43Pocket No. AC-5 Adopted: September 7, 1943Released:                                    September 9, 1943EXPORT OF PC CIVIL AERONAUTICS BOARDOn rhe I ivestisatnon of -ip <-.ccideit, 1n^olvxnj aircraft of United 3Ute: rejigbry NC 10503, in t.ie T-iyus Rimer, Ii^bon, ForUgdl, on February 2-2, 1943. - 1 - An accident involving &n circrai't of United States registry, IJG 12603, a Boeing 314 flying boat, occurred m the Tagus River approximately 2 rules east of Cabo Ruivo Airport, Lisbon, Portugal at about 18'47 GMT (t>:47 p.r..) r on February 22, 1943 which r esulted in Fatal xnjuries lo 19 passengers and 5 crew members. Of the renaming 8 passengers, 2 received serious injuries, 2 minor injuries and Z were uninjured, while 7 members of th : creu received injuries ranging from minor to serious. The aircraft, jhach '.us being opera- ted by Pan American* Air .jayr m scheduled a:r carrier service us 2rip 9035 between New York, II. i.; Derruoa; Horta; Lisbon. Portugu?.; and F-yn'S, Eire, was demolished. COU'VGT OF TZVEb^ISATiOil * The Washington Offic? of the Civil Acronr.ut_.cs Board (hereinafter re- ferred to as uhe Board) received notification cf the accident the night of February 22 and on February 23 initiated an inver Ligation in accordance with the provisions of Section 702 (a) (2)2/ of the Civil Acrcnavti<'s Act of 1333, ao amended. Two representatives of the Board, Allan P. Bourdon, Chief, Investigation Division cf the Safety Bureau, and Howard T. Bailey, Technical Consultant to the Civil Aeronautics Boaro, picoeenod to uh, scene of the accident, leaving New York on February 28 and orri^'ing st Lisoon the afternoon of March 4. In tie meantime pnn Ajie.rxcar was authorized bv th-. Board to proceed with salvage operations. All of the wreckage that was re- covered from the river '-as deposited or. ths dock at Cais de Canta Apo3onia, Lisbon and there remained under constant civil police guard until f orally released to Pan American An r ./ays by the Safety Bureau.1/ Section 702 (a) (2) provides that it shall be the outy of the Fond to "Investigate such accidents and report to the Authority th facts, con- ditions and circumstmccs relating to each accident and tn? probable cause thereof." 2 -HearingCaptain H. 0. D. Sullivan, wno was m command of the aircraft, madehis first formal statement regarding the cause of the accident to Commander                                                                             XPaulo Toixeir Viana, a representative of the Portuguese Government at                                                                                   7i IFLisbon on March 5 in the presence of Mr. Bourdon and Hr. Railey of theBoard. During the investigation at Lisbon formal statements were securedfrom the other six surviving members of the crew, five of the eight surviving passengers and eight members of Pan American ground personnel. 2/ In connection with the investigation, a private- hearing was held inNew York City April 16 and 17 before representatives of the Board                                                                    S tuartG. Tipton and Allen P. Bourdon, presiding officers, Ralph A. Rood,                                                                       SeniorAir Safety Investigator, and W. E. Koncczny, Aircraft                                                          Specialist            At thistine direct testimony was taken from Captain Sullivan                                                          and four members ofPan             American operations and maintenance personnel and                                              additional testimonywas                  taken           from throe members of the crew. E the basis of all the evidence accumulated during the investigation,' Uponthe             Board                now makes its report in accordance with the provisions of theCivil Aeronautics Act of 1938, as amended                                                                                                                  ItAir CarrierAt the tirao of the                                ccidcnt Pan American Airways, Inc,               (hereinafterreferred to as PanAm)                                             Heiz York Corporation, was operating                 as an air earnerunder a certificate of public convenience and necessity and                                                                 an air carrier operating certificate, both issued pursuant to the Civil Aeronautics Act of1938, as amended. These certificates authorize PanAm to engage m air transportation lath respect to persons, property and nail between variouspoints, including Now York, Bermuda, Horta, Lisbon, and Foynes.Private hearings are held when for reasons of national security public hearings                             are inadvisable. Flight Personnel The captain and commander of the flight, R, 0. D. Sullivan, held an air- line transport pilot certificate, with 0-7230 h.p. s_ngle and multi-engine land and sea ratings. He also held the PanAn senior title of Master Pilot. He entered the employ of PanAm on September 3, 1329, after serving approxi- mately 11 ^ears with the U. 3. Navy djir.," which <tune ho had acted as flight instructor and test pilot at various Nrval Air Stations throughout the country. Ills total flying time on Boom-, 314 equipment was aoout 3273 hours and his total flying tjjne was 14,332 hours. He commanded tne survey flights for the Trans-Pacixic route and, with the Inauguration of t^c Trans-Pacific service, participated m 55 such Pacific crossings before being transferred to the Atlantic Dovisior. On this cwis*"n he commanded the Bermuda clippers until.the inauguration of the Trans-A clan-ic service, Prior to February 22, ,1943, he had, as capta_n, completed 100 successful Atlantic crossings. His last physical examinetion, required by tne Civil Air Regulations, was taken on October 13, 19-2, and his company pre-departure physical on February 21, 1343. First -Officer H. 3. Rush held c conrircial allot certificate .ritli a  -0-325 h.p. single-engine land rating. He v-as employed by PanAn on July 7, 1941.- He had logged approximately 1706 hours as copilot with PanAn, 1a54 hours of this tinv were on Boc-rnng 314 equipment. His last physical examina- tion, required by the Civil Air Regulations, was taken on I Ioverier 19, 1942 and-Ins .company pro-departure physical examination on Febniary 20, 1943. The aircraft The aircraft, NC 13603, a Boeing 314, 4-cngine flying boat, Serial No. 1390, manufactured by the Boeing Aircraft Company,was delivered to panArc in January 1939. It ras powered by four bright 332C-14AB1 engines, each with rated, h.p. 1200 (ruxinum. except take-off) and 1550 h.p. for take-off. They were equipped with Hamilton Standard, constant speed, hydromatic, See our selection of aviatioon documents at RareAviatioQ.com full-feathering three-bladed propeller?. Au the time 01 uhc accidenu, tmsaircraft had been Flown a total of S5O5 hour.,.Wet, th or * >im an H an ---, ,The weather at Lisbon at the time of the accident was cloudy, li; ht in-termittent showers,                                                                                                           visibility 7 males,                                                                                                ceiling 4tG0 feet 'uth scatteredclouds c.t 2000 feet,                                                                                                              surface wind TTjJ 6 knots.                                                                                                                The tide as citing; st 2 mots.Official sunset was at 2 020 GIT? (6:20 p.m.)                                                                                                                                                                                                                 A thunderstorm had passed south ofthe Lisbon station ct shout 6:00 p.m.                                                                                                                                                                                     movin '7NV7, and int er. iitucni lightningflashes vrare observed --jot of the flight by J h ' cawtun, rosserrers and nenboisof the crew. The surface vmd sieved clockw.mc from fi L 6 Irnots at 5:50 p.n.,around +0 T o mots au 6; 33                                                                                                                                                                          end was reverted to the flignt as V.TL7b knots just previous to the ac.id^riv.Hi-ptorv of the Pl; g j,t .   -                    11*  ---                                    -Trip Io, 9035 originated g, non fork, proceeded to Ecmud-o on February* and                                                                         arrived at Eorta                                                                     at 10:18 a.m. (Gift) on February 22, after a routineflight                                                                         After servicing                                                                    and refueling the flight took off iron aorta at11:43 a.m. (GI2T) with sea conditions as follows: Channel swells iron 2 to 3feet high; surface waves, none; wind from sox.th. 3 knots. The flight maintained an altitude of : ppro:3.m'tel;r 7000 feet until itapproached the mouth of the Tagus P.ivcr,                                                                                                                                                                                                          approximately 11 miles from. Lisbon,when a gradual let-down was ?du to about 600 feet. The Portuguese autnori-ties require That                                                                                   ulus altitude be r.3intamed from the mc.uth of the river tothe landing area.                                                                                     The flight arrived over the area nt about 1335 GIG (6:35p>ni>Lisbon tirierH 6 hours                                                                                                                   nJ 52 niiwtes after take-off from Korta and 15 minutesahead of its estimated arrival tine.                                                                                                                                                                                                                       official sunset was               at 6:20 p.n.,PanAns ground crew it Lisbon nod set                                                                                                                                                                                     out us usual a string of landing lights,indicating that                                                                          the landing xv.s                                                                                  to bo node from south to north.                                                                           On this par-ticular occasion the light arrangement was slightly different from normal,sines the extreixe doxnwixid (south) lignt, v/hicn was usually green m color,3/ AH tine roicrrod to hereinafter is Lisl;on                                                                                                                                                                                                                                  line.had b?en replaced a white light. The only reason for this change was that the green bulb had burned out and tne PanAn station substituted tne white bulb. Captain Sullivan indicated in his testimony that the substitution of lights vras not confusing and had no bearing on the accident. This string of five landing lights extended ov^r a distance of approximately 4500 feet. At the time the flight, arrived in the area it was still light enough for the air- craft to be observed plainly by personnel in the PanAm launch and on the shore. The PanAm launch had patrolled the landing area oust cf the string of landing lights and had taken its station near the red light which was the extreme up- wind (north) li fat of the landing strip. The landing conditions and barometric pressure .zero given to the flight by radio at 6:35 p.n. and were acknowledged with a statement from the flight that they would v/ant flares when both landing lights were blinked. rrhile pro- ceeding in a northeasterly direction, at an estimated speed of 235 knots and at an altitude of between 500 and 600 feet over the area, about li- miles east and abeam of the center light m the string of landing lights, the aircraft made a descending turn to the left which continued until it was headed in a v^osterly direction when +he left wirg tip skimmed along the surface of the water, dug m I and the plane crashed into the river. It renamed partially submergea for ap- proximately 10 minutes, then disappeared below the surface of the river. The PanAm launch, which bad been standing by for the landing, proceeded to the scene of tne accident, arriving about 10 minutes later, ana began rescue operations. The PanAm launch was joined by a BOAC launch (British) and another PanAm launch approximately 10 minutes later. Witnesses The first officer (copilot), who was at tne controls ;rith Captain Sullivan and could have proved a valuable witness, was one of the 5 crew members fatally injured. All witnesses, except the captain, agreed in general thatthe course ana attitude of the aircraft seemed normal until the tunc of impact. It appears from the evidence                                         that just, previous to and at tho tune ofthe. accident,                       all nine members of              the flight crew and the supernumerarywore on uhe flight; deck and their                                    appro.cimuuo positions were as           follows:Inc captain and first officer were m their respective pilots'                                          seatsj thesecond officer (navigator) was standing just behind and between the pilots;the thira officer ns standing behind uhs captain's seat; uhc fourth officer pwas standing behind the first officers scat; tho assistant engineering officer "as seared ct tie engineers' table: the first radio officer was at the radio station; the engineering officer was ssated on one of the jump seats; The assistant radio officer t/as occupying the other jump seat; and the supernumerary 'was at the navigator's table. Tho captain stated that he entered the Lisoon area ov;r r,hc mouth cf rhe Togas River at an altitude of about 60U feet and proceeded m level flight m a northeasterly direction up the river on a course which took him abuuu 1-| mil~s east of the north-south string of landing lights. He seated m substance that it was his intention to continue north over the t landing area until he had passed the north end of the landing lights, make a 180" turn and return south to a point sufficiently south of the white landing light to allow for a normal approach fcr a scuth to north landing. However, while he was still headed north ana about abcan of the center light of the string of five landing lights, the nose of the plane soeiaed to drop slowly. The captain stated that he was not alarmed nor did he realise he was in trouble until ho baa descended to an altitude of about 400 feet, when he noticed his air speed was about 135 knots and that the angle of descent bad increased to approximately 45. He testified that he pulled back on the elevator control ana found that there was no pressure whatever on the control yoke. He stated, "my first officer, he grabbed the controltoo" m an effort tc assist him regain control. Thd. captain stated that it was then s-. - - -               See our selection of aviatioon documents atRareAviation.com             * ' '                                                               - 7 -  that he was sure he was going to make a crash landing and decided it would s be best for him to absorb some of the shock with Uie wing; that, accordingly, at 2-00 feet, he throttled his engines and applied left aileron control, He stated that he knew he had aileron control but was not cure about having rudder control because he did not try to use the rudder; that he did not know why he did not use rhe rnm tabs or apply more power to bring the aircraft out of its * descending attitude, He stated further that he had no conversation with nor did he make any remarks to the first officer regarding the trouble. In Captain * Sullivans first forrul statement, given m Lisbon or iferch 5, 11 days after the accident, be '/as asked why, 'hen he us at 4-00 feet, he did not try to- remedy the nose---down condition by accelerating the .igines instead of throttling them, to which he replied, MI donr think it would be a wise thing to try the motors at that altitude, When questioned at the nearing- in lie/ fork on ^pril 17 as to what, if Anything, he aid to regain control of the aircraft st the time he stited the plane nosed down to about 45 at 1;OG feet altitude, he in- . severed, "I am afraid I am better off not to try to sec wh?t I done; I have no idea." When asked whether he "might have changed the stabilizer setting", he answered, "If I did not, I should have. That really woula have been rhe first thing I should have done, I dont know whether it was changed, or whether it was not, I dont remember doing it," Alien asked, "Do you think if you had done that you could have raised the nose of the ship?", he replied, "Well, I do not see why in should not, because it 'Iways acted very quickly to the tab, to the,control." vQien asked whether he had had any intention of making a landingin e direction other than south to north, he answered in the negative. During the erptains first statement at Lisbon on March 5 he gave no estimate of the angle of descent of the aircraft. On the morning of April 17j he accompanied a tost flight in a PanAm Boeing J14 m New York and late that afternoon at tht, hearing he stated that he "sat in the cockpit this morning taking an angle, level, and then taking an angle of the glass where I last seen .                                                             i -w          -    --- ji  *   * r t JV Tir 7 See our selection of aviatioon documents at RareAviation.comthe beach going out of sight ano making nn rngJe about ^5                                                                                                                                                          Thar 3 s the only vny1 could give an estimate on the angle it vvar in"The airport manager                                                                                                   who was sbanama at che radio in rhe airport officef at Lisbon, stated that, "At the time the plane                                                                                                                                        last reported on radiophone,it was approximately 2 to J miles southeast of                                                                                                                                        Cabo Ruivo at approximately 500feet, heading m a northerly direction.                                                                                                                     About 10 seconds latei;, I apparentlyhad                                                 r  lanced usid                       for an instant,                                  I sew th5 plane                                              at approximately UOO feet 0 r  tan" altitude in. a sharp descent, estimated at 20."                                                                                                                                                        lie stated further, "The planecontinued in this 20 descent until                                                                                                                it hit ths water, but because of darkness1 can't                                              definitely                          state whether there was                            any leveling ofp or not at the end/ VThree witnesses                                                                                             (passengers)       seated in the same compartment on the porbside of the planes                                                                                              one of them facing forward                                        and the othr two facing aft,testified.                                                            One of these passengers stated,                                                                  "Js 1 turned ny he^d from the windowI saw the wing of the plane skim along the v.atcr. It didn't go in, it skimmed along. I turned my no nd awry from the vandow . .  It ^ns then that I re-ceived this series of shocks.  .     Another s^id, I looked dom. I was watching the water below. I saw the wirg tip touching the water. Even to thatpoint nothing made                                                                                              me think vre were crashingThe PonAr conmuni^atz ons representative, awaiting the arrival of the flight, was on dutv at the radio telephone . nd was standing next to the airport managerm the radio room of the airport office at Cabo Ruivo, ana observed the aircraft approximately 2^ miles distant. I*e stated thwt he overheard a rodio telephone communication from the PanAm launch to the aircraft which was acknow-ledged by the flight with the following remark, "I'll nak^ a circle to the cast of the landing lights/* The witness stated that imediately after hearing this message he glanced out and the aircraft had already hit the water, "it was just That quick afterward." Vhen asked if he could gve any estimate of the lapse of cime in seconds or minutes between time the message eerie over and the time he saw the splash ho answered, "About thirty seconds or less." The witness was not sure whose voice he had heard, Captain Sullivans or that of the first officer, but he stated, "I think it was the first officer. 1 dont know why, but I think it was. The ssistont to the traffic manager m Lisbon, a Portuguese -,rh^ speaks English, was also standing by the airport manager and saw the plane through the window of the airport office. The radio man was ir communication with both the flight and the PinAm launch and asked the flight if they needed flares co land. This witness stated, 1 think first he said, 1 need flares in a moment - night flares. He quoted the flight saying further, "Now Im going to turn it up, I will turn to face the wind to land, The witness said that he thought he saw the plane making o left turn. He stated that, "At that moment 1 sow rhe vmgs turning up, I coulu sec a little inclination of the wings, more than normal. .... .and I saw the red light coming down about 1^. (it is evident that the witness was referring not only to tbe longitudwal attitude of the plane but that he saw the red navigation light, which is on the left wing, move downward as the aircraft was headed toward him and was steeply banked in the final turn, as described by most of the passengers.) The vntnoss continued, "I just saw the rea light stopping n-ar the water, I couldnt sec exactly the line of the water.   .Then I 10 -heard a big boom far away first of course I thought of a forcedlanding                                             I was looking at Mr.                                Anderson (the                             airport manager) at my sideand we were astonished trying to figure wnat it was.The fourth officer testified that he had gone up on the flight deck15 to 20 minutes prior to the accident and he remembered that the flightwas absolutely normal;                                                                             also the altitudes y.hich ho had seen on the navi                                                                            Ifrgator's altimeters, the air                                                                                            speed, and many other incidental things,3 eluding tne first officer's                                                                                            repor-t of a radio message from PanAm Lisbon tothe                                          captain taat the landing launch was at                                                                               tnc north end of the landing ligtesand he noticed that the captain acknowledged this information. He testifiedthat,                                                             "The captain began a                              gentle turn to                          the- left                         For some reason, Idont know what, whether                                                                                      I heard something,                                     whether someone spoke to me orwhether I was just looking around,                                                                                                     I turned ny head to the- right and Incard a crash,                                                                        ard that is the last thing I recall but at no time had anysensation of the ship being in"an abnormal attitude. Further evidence of the smoothness of thu flight prior to impact wasfurnished by the testimony o' the assistant engineering officer. He was stated at Lis tabla on the flight deck and recalls that the captain *'as occupying the port seat and flying tnc aircraft, and tnau tne first officer was in his seat cn the starboard side. The engineering officer was also on th cock. Tnc assistant engineering officer said he had not received any I instructions iron the copToin and from his t^suomony it is evident that be did not pay any particular attention, but knevr thjy nad lot do*TL and as be expressed it, "There was no clipping. If wo wore coming down at all, it was very gradual." He stated that no Look a Iook out the window and "it was in the turn, because of the fact I could see down on the ground ouu the port windows and cculd sic the clouds at the otnar windows. . . . .Every-thing appeared to be perfectly normal m every respect, including the airplane See our selection oLavJgtioen documents at RareAviation.com and the engines .... He had made a turn and ao.-arently, to rcy s rise, he had leveled off and was oroceedmg to land and had closed the throttles. That is why I looked up to see whether it was time to gave him power or not, because of the throttles being closed." When questioned if tie captain cut the power himself, the witness answered-, "Yes." he said that at tms moment he heard a snap, that it was "after I distinctly remembered seeing the throttles moving back I heard the snap." From this point he could not re- call anything further until ha regained consciousness in the water. None of tne passengers who gave statements at Lisbon or members of the crew who testified at che hearing had any sensation of falling or .witnessed any indication of tnc impending crasn. All of the witnesses referred to above seemed to think that the aircraft was in z. normal turning glide pre- paratory to landing. From his ocsiti-n on the ground, one witness, the airport manager, estimated ths descent to have h^en 20, whz.cn would have been equivalent to a descent of between 3COO and 4000 fe^t per minute. Had the aircraft been descending at 20, such a descent should have been noted as unusual at least by members of the crew. Had the aircraft been descending * at an angle of 45% as stated by the captain, it is reasonable to believe that the passengers would have become alarmed and certainly members of the crew would have become conscious cf the unusual steepness of tne descent. Recovery and Examination of the Wreckage Recovery of the wreckage war started ths following morning, February 23, and as parts were takan from the river they were places on nearby Cais de Santa ApoIonia Dock for subsequent examination and study. The extent of the damage to the aircraft structure, as it existed immediately following the accident, could not bo determined vnth accuracy, as uhe action of the tide on the wreckage while cubnerged, together '\ath tnc subsequent salvage opera- tions, undoubtedly contributed somewhat to its further destruction. It appears that the aircraft struck the .rater ;ath sufficient force w result m groat damage to the hull ana the loft '.ring, vrhich was completely sheared off at a point just outboard cf the outboard (No. 1) engine. The recovered portion of this ring revealed extensive damage. The complete flotation uing tip section was not recovered. The remainder of the wing structure, including the center section "which carries the four engines, and the right wing and wing tip, received comparatively little damage by water impact. Engines Nos. 1 and 2, cowling and parts of the nacelles were torn from the center section by impact and m both cases the propellers were broken from the engine crankshaft. Engines Nos. 3 and 4 received only minor impact damage and were recoverca intact with the center section. The hull was badly damaged and had sustained at least two major breaks - one im- mediately aft of the rear wing spar arid the other just forward of rhe em- pennage. The major portion cf the hull between these two breaks was notrecovered. That portion of the hull forward of the rear wing spar and belowthe                            flignt deck had disintegrated and nearly all           of the hull bottom and themajor hull structure wore completely torn away.                                       Portions of the flight deck,however, were recovered with the center section.                                           Both hydro-stabilizerssuffered major damage, the left one in particular being badly mangled. Thesevered empennage, which was found                            some distance away from the main portionof the wreckage, was                                        recovered m comparatively good condition except thatthe outboard oortion of tee left elevator was missing and was not recovered and the left fin and rudder were sheared off from the stabilizer but werestill attached to it by the control caoles. This severance-was apparently caused by impact with sone heavy part of the disintegrated Tjreckage, such asa part of the left hydro-stabilizer or tee No. 1 or No. 2 engine. * 15 * All rudder and elevator control cables had either parted during the separation of the empennage from the major portion of ihe wreckage, or remained intact and vrerr pulled through the stabil-zer structure, carrying  I ,ita them portions of the elevator control mechanism. / An examination of all parts of th" axrplan^ rccovex-xi from the river, and a study of the various instrument and control settings located on the flight deck, rcvoalea nothing which would explain uhc cause of the accident. There were no signs of fire or explosion m the v/r^arage, ana there were no indications of malicious tampering or sabotage, a In view of tht, captains statement that nc had lost elevator control at the time of approach to tue landing area, rhe salvaged elevator control system parts1 and portions of the horizontal rail surfaces were returned to New York. Some of these parts were subsequently forwarded-to Washington icr further study by the technical staff of the Safety Burecu with the co- operation of the Division of Metallurgy of the National Bureau of Standards. The Elevator Control System ~(Sco sketch on next page) The c-levator control system of the Boeing 514 consists of two sets of cables wnxch permit operation of the elevator tnrough an initial range of approximately 20 either side of the position cf zero hinge- moment by means of servo-tabs,^ An additional 5 notion in either direction is attained by A direct operation of ths tlavator through the torque-tube. Thu 5bur ends of the operating arms orc also connected to ths torque-tube by moans of four independent spring-cartridges. The purpose of tnese cartridges is to permit the operation cf the tie voters through ths normal operating range by means of * the servo-tabs, while still permitting direct operation of the elevators 4/ Servo-tabs should not be confused witn. trim-tabs, whicn arc separate on this mcdel airplane. See our selection of aviatioon_dgqu merits at RareAviation.comthrough the extremes of their operating range by means of the torque-tube. The only individual faulures in the cable control system which couldrender the elevators inoperative are the two cable connecting links whichwere recovered from the wreckage undamaged and intacu.The dual set                   of cables enables                   either the captain or                first officer, orboth, to operate the system in case any one cable fails. If one of the servo-tab systems should become inopcrativ, one other set would operate the* elevators sif facinnLl- for control. Evt>r the failure of r^e hia^c bolt tAp- ** porting the oo-raeing arris, or the failure of the actuating lever, would notdeprive who airplane completely of elevator control.                                                     The failure of one, oreven all four of the                                     cartridges would not           influence the operation of uheelevator through the first 20 of                                  surface movement.Sufficient parts of the elevator control .system umre recovered to purrat detailed examination and stud'- ana to establish bevor.d reason.. bl- douot that  the system ' as functioning prior to impact. The only 'lenent found to hemebeen broken was the rod of rhe lower starboard spring cartridge. This break had the appearance of having occurred sometime prior to the accident. However this finding is not considered' to be relevant in establishing the cause of the accident, inasmuch as even hod this cartridge been broken, it would have hed no effect cn the op ration of the airplane. Although tms conclusion seemed quite apparent from a study of the design of tn< elevator control r system, nevertheless tao Board arranged with PanAn for sppcxtic tests to 4 clarify this natter beyond a coubt. During these l^SuS, one or more of uhe ' c&ruric^cuure dio connected and tnc operation of the elevator control s vs ten vras found to remain normal. suijAR? Aim a:;alisjd OP evidepcb ? fu.cn consideration was given to Cap win Sull ivans description of the * - events inncdaarel;/ preceding the crash; specifically, that -vrhile approaching the larding area at 600 feet, ihe airplanes nose dropped for no explainable CIVIL AERONAUTICS BOARS ACOOENT LI SB J" POATU&AL LO 22.IV43 wi'                                          See our selection of aviatioon documents at RareAviation.com .r1'-                                  - 15 -reason, and that subsequent endeavors on his part and on the part of thefirst officer to recover from thx increasingly steeper glide were of noavail due to lack of elevator control. A study of this airplanes structuraldesign, its flight characteristics and its operational features fails to disclose any reasonable explanation for sucn behavior.I Even ?f for sone unexplainable reason the airplane had entered a glide under tne conditions described by the captain, recovery undoubtedly cuuld have been attempted with at least a rood chance of success by means other than the use of elevator contiol. To verify this possibility, actual flight tests were conducted at Now fork in April by Paiu-n cn another Boeing 314, rath personnel of the Board and Captain Sullavan participating as observers.These tests prov- o that                                                       recover;/ from a glide of the same speed and powerconditions as described                                                 by Captain Sullivan,            could bo effected very easilyand without appreciable                                                 loss cf altitude by either tnc application of poweror use of the tr_m-tabs.VJhon questioned, Captain Sullivan did not recall vrhether or not he hadnadc any endeavor to recover from the glide bv means other than the use ofthe elector control.                                nithough undex* the assumed cireinstances a pilot of hisability and experience should certainly have used at least the trim-tabs, Inthis, as in other respects, his xccolljction of the events irriediatcly pre-ccdin^                    the crash was uncertain.Fine1 mgs 1. The accicont occurred in the lancing area on th~ Tuyus River atpassengers, 2 received serious injuries, 2 minor injuries, and 4 wore un- injured, while 7 members of the crew received injuries ringing from minorto serious. The aircraft, a Boeing 314 flying boat, !IC 186O3> was demolished. See our selection of aviatioon documents at RareAviation.com 17 - 10.  There were no signs of* fire or cxplos?.on i,n the wreckage and no indications of malicious tampering or sabotage. 11.  The weather, direction of the wind, intermittent lightning flashes and reduces visibility due to darkness cannot be considered as contributory to the accident unless those condition influenced tne captain to land from east to west, instead of with the landing lights from south vo north. 12.  The captain indicated by his testimony that it was his intention to make his landing from south to north after circling the area to the left. However, testimony of the surviving passengers, croxv members and other wit- nesses indicates thit they thought a lending was being effected when the crash occurred. There wus definite evidence that the airplane was headed in a westerly direction at the time oi impact with the water. Conclusions  * The Board finds no convincing evidence that the accident was caused by failure of any part of the aircraft, or in particular by a failure of the control system. The captains recollection of the behavior of rhe airplane, i.e., that it entered an abnormally steep descent some timv prior to making contact with the water, was at ,ridc vr nance with ths ricollcctiurs end tostmonv of the surviving members of the crew and surviVDn; passengers, x*o indication could be found in the wreckage of the control system which would account for any failure of the airplane to respond to the controls. Had such a failure occurred when the aircraft was at an air it ide of J30 feet, as rhe captain testified, it is logical vo assume that he would surely nave had some conversation with the first officer or that he would have warned the other members of the crew on the flight deck of the impend ii* crash, furthermore, it is believed that hud the situation been such that the first officer found it necessary to assist the captain in an attempt to regain control, and had the angle of the descent ofthe aircraft been as severe as h5 from an altitude of 400 feet until it struck the water, to uh-iTh the captain alone testified,                    surely one ur Loth of theunusual circumstances w_uld have been noticed by au                             Isa st one or more of thesurviving members of thr crew.        AD so,            this severe      angle of            losccnt wouldundoubtedly have made an impression an th 3 surviving passengers.The direction of tne wino. and the rapidly approaching darkness mighthave influenced the captain to land from east to 'vest at a right auric to the landing lights If such I'as tno case, and in vie:; of the marginal day-light renaming, the accident night will have been the result of misjuagmcht of altitude whil^ executing a turn preparatory to landing, winch resulted in the wing tip striking the wav r. Although Captain Sullivans testimony does not coincide with these conclusions, t x? besLimonv of renters of the crew J                                                        Cr* and passenji rs who survived dots at least support this theory, inasmuch as they had no other thought than that t-.e airplane 'was making a normal landing at the time of tbe accident. It is inconceivable chat all of the witnessescoulc have had this impression aad the airplane descended from 400 foot at an angle oven apnroaching 45, as testified to by the captain.The description of events just prior to the crash, as given by Captain I Sullivan, was not corroborated by any otn* r iitncascr. It us probable that the captains inability to recall accurately the events md details of his actions from the 400-foot altitude until striking uhe water its the result of mental and physical shuck. If j as stated by the captd.un, he was w attempting to land and the X elevators did. bee one inoperative, which investigation failed to reveal, he erred in not attempting recovery by use of the trin-tabs. Captain Sullivan agreed in his testimony, and subsequert flight tests indicated, that the use of the trim---taos should have enabled hm to regain control of the aircraft* If^ houvovor, rs the preponderanc of evidence so strongly indicates, the captain was attempting to land the aircraft at the t^rne of the accident, he erred in his judgment of the position of the aircraft in relation to the From PilotManuals.com / RareAviation.com - 19 -water. Good airline practice does not allow a turn at so low an altitude where a very minor error of judgment would result m contact with the water. PROBABLE GAUSSIt appears that the probable cause of this accident was an inadvertent contact of the left wing tip of the aircrait with the water while making a descending turn preparatory to landing.APPROVED:/s/ L. Welch PoeTue L, Welch Pogue/s/ Edvjard Warner_____ Edward Warner/s/ Oswald ay an Oswald Ryan/s/ Josh Leo__________ Josh LoeHarllee Branch, member of the Board, did not take part m the decision. 'A   dcptcci: November 7,           1944'  File No* 1191-44REPORT.OF THS SIVIL AERONAUTICS BOARD on the Investigation of an Accident. Involving Aircraft During a Scheduled FlightWhile proceeding under contact flight rules ever snow-coverea. terrain vzhich made visibility uncertain, a Pan American Airways plane on a scheduled flight from Kc-:.P t Fairbanks, Alaska, crashed about 3:48 p.m9, Bering war Time, April 6, .144^ approximately 1# miles east. of the CAA Field at Nome, All"'occupants, including the pilot, -tw crew members and three passengers, were fatally, injured and the aircraft, a pilgrim 130-B, was demolished,.CONDUCT OF INVESTIGATIONThe Fairbanks Office of the General Inspection Branch, Civil Aeronautics Administration, was notified at 6:00 p.m., April 6, that NG 74?-N was overdue; and about'8:00 aom., April 7 that, office was notified, by                                                           pan American Airways, Lie, (hereinafter referred to as Pan American) that the wreckage ted been found. Due to the unavailability./ of an:Air Safety Investigator of the civil Aeronautics Board (herein- after referred to as the Board) the Civil Aeronautics Administration made the investigation for the Board, CAA Inspector D. lih. Gretzer : arrived at None at .3:05 p,ro,, April 7 to begin his investigation. At that time the bodies ted been removed and such mail and cargo as be handled without disturbing the airplane had. been removed-..On the basis o                                                                                                                                                     the informal ion .furnished by the Civil Aeronautics . .Administration, the Board -now makes its; report in accordance with the /provisions of the Civil Aeronautics Act of 1938, as amended, S1MIARY Al ANALYSIS OF. K7iWCE:Air Carrier >At the time of the accident , pan Amer/zoan--was operating Under a certificate of public convenience.and necessity authorising in to engage., - .in air/transportation with respect to persons., property and/nail between . .  various points in .Alaska, inciting: Nome, bfoses Points Nulato and Fair- /bank&c Flight: Par sonnet. Captain Robert Leslie Bullis of Yakima, Wash,, held.an airline transport certificate with C-22@0 htn* single and itthlti-'engine land and /jsea, and flight instructor ratings, ... had  logged :abopt. 3477 hours.,; .114 of which were on the type aircraft involved.. He had flown on. the -^pmerun .since August 1943 and had made seven flights to IJtEfie as captain*. - - From PilotS&ti&als.com 7-R.areAviation.com - 2describe i                                          Pan                                                    nee .s flight as                                                                                                                                                                                                                  <3t?ebrnic c;rt i f t on                                                                                          a:xKi sjk-:- rs.*ch ex s-diroan- ?. aircraft- and'ennin<> xOe6hOT                     '. ...The Tdrcraftf The -aircraft, a Pilgrim 100-B,    742J,                                                                                                                                                                     3t?xdan                       th a Vrii'hdM820F-?I engine of ^Cb-P' g'?             f            -..; .assy January 1944- The take-off W$gbt at the vise ox occ-u-.iu; f& W' po^s, rMch^s:fU:'the tinje.Qf the:accident.the plane was eparsvn^ cn axis.- It S  equipped ?<ith de-icers .                .            ''.History of the Flightthe'.go3S3 GA4i'..|^4 c-bslt 3:35-.-p-*9.,- >Jf{rsc ^,v.^ Fairbanks Mth stops.sch-3da->sd.-.-.at point, h:lato, tiaj^iss.-sw Tanssa.. -,. - .          ?.,;'*.  w                        :  :'i-  _  .....              r ii   . . .s : .. - 2**s * a. kV.jTI       '" Jb-aXtitud ,^hs assigiied-siheO-the                                                                                                                          clstrsKd^-rsss f'5F psjxltct flight                               f-ra-c tiled;. biit:;becau.se-cf: pteTO^                 it.tyafe. ^^eSitkuJ'.thg- flig'n                                                                                                                                    t srouisi at an altitude - somewhere b';tv?ocn IffO                                                                                              ?nd 1500 fret,                                            rj'lnd. vt;s ecst                    1? to ; i 21 m. p, hl', light sn<rT -was falling.  and                                                                                           the ceiling ms                                                   vaeigbxa*: The only;radio contact  Kith                                                                            Cartels. 50-lib sftsre exchange of aessages sith. r^rerd                                                                             tb- . p nothdr  ?z-n fao r loan  .al Icckheed cpaing>in-to 'Kone ilchg                                                                              thd' 00-S.t fpSlS -the .aae-t*                                                                 11   5 off' his heading : of -.. 'ea0rsbuthc.es                                                                       the coait If                                                                       *>            ; heading of northeast, toi.ard.the                                                                                                                                                                 *    * s 1 *     . > the tisc of this radio contact. It^as-bsth                                                                                                                                                        * f      F        Ac land - ths Pilgria passed. pach: otfe                                                                                                                                                                               V J 3:45 ?.*.rroin -the. tine- pf: ;ths  turn W.-^d ti"                    ^*r>         -<*-** 4                             cisMaa - . Aa-xuv  *< - v - certain        -au^ ai- ?i             < The-g;-.-a ths Filgri .Al*                         height/ of_                           fd :I ^..;?wrd-.off -:ite .heading,itheii.^ifckly                     ^is                                                                                                                                                                              use - *-                          J .x-mWWi&aj   Wfcuis*. 'sasS' biitogf.. sat?W.     - Wit              Examination of the Wreckage .'Examination of the wreckage'indicated that the' plana struck.-.the.-/                              B                                                                                             w                                                                                                                             *                                                                                                                                       J "                             w                   *                  *                         1                J1     *             J ---ground in ?, steeply banked attitude at a high rate of 'vortidhl desc-pnt and with great ferrand speed. Apparently power was on at. the moniont. of impact. The right wing struck first and the airplane"skidded alpr/g/t^'dground 39 feet into a depression, bounced 20 foot beyond .-the hal&/ahp'X came to rest on-the right side 6f 'the-' fuselage. ' Tlfere- was. no' eyldcMfe// found of mechanical failure or malfunctioning- of-ahjr'part prior to impact.                    '' /                                     .'ivgathcrIn Alaska there are' areas that are either rolling. or flat and without contrast, such as trees, jutting rocks, buildings, -etc,  llcomplete snow cover - exists, the landscape assumes an unbrhkop During an overcast, particularly-fith haze or falling 'phd??, -thd - completely disappears and, in effect, instruraunt conditions exist'/ 'when there would be fia'-o or six riles visibility if -rdfarenes marks/y/ available. It was established that Captain Bullis shcGuntsrsd such./:-, conditions, from.the time ho left ths- coastline- to- the point of ths  accident. Even the existence of -ons cabin near .the-scene. c-f.th-//./' crash was not sufficient to establish. the horizon or. contour of .t&CAA InspectorIt has not --                                                                                                                                                                 been determined why the- pilot did:,/saipfcih ..I-altitude-to.clear any obstructians,                                                                                                                                                                                                                                                                                                                           he undchfetodly/was-f the height of the terrain and .with' the illusibnp/'bred - snow conditions. The weather report at Some shh^d"--.B<                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     OOG-f cot' btl-lirgsi I -         *         i                                                .     -         *-  4  r4 a *      * - light snow, temperature 32, and. d-ow point-28i-  Tbithat-aircraft icing existed, under these conditions;,:- incliidihg:.the ; heated venturis which supply air prossur.& to . ppGrate - the'/prosep^ : instruments. Such an icing condition could hays-                                                                                                                                                                                                                                                                                                                                               c-6iitributdd -fe . confusion in conducting the/flight...DiscussionOrdinarily,  under such . conditions. :-of visibility: ss- prevailed: -at/i'l'/:. - - *hc time of the accident, pilots 'an-the fioato---J'airbspks 'run-Biay/npir' ;BMp-coast if flying- oohtac t / bdcsxisu of the sharbly.^ -. where /land -and water Iseet.' - Inland . the''/blending,of - thcr s-npw---oyorpd/./ .;/ground', /ha. '-and/clciu-ds. makes  it,difficult- for- the/pilot-- //,/-where./the- plan i-$ 'with'.' refcrehce-/to the surf see, ' /.ty Spills^               fly -^thc^-yputsy-; --Why  he -turned ihls^ _,/' .cpastal  heading -could . riot btr determihod, but -it .is- possible ;hp pa.d/ Bp- o/i:-either to ayoidWe Lcckh^ib which rns flying. toward7 or (id/fly the beam. ."-If Any inergcncy existed, it is apparent. ,, .:  -A, r - -j ." 4                                         , -                .                        - ._                 ,  . .                                                                 -  - _ - '   " ' ' .  * * . .       --     .  -  From Pil0tM^u6ts:com ^^reAviatipji,.cdFn /'           '      .                                                                '"                   9'                            1                      I                                                                                                                                                     '                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          K                A".- >/ > * 5that the < passengers were not am'of it 9 eatabXiaft^ tut they were eating; at the lipaent of xspaet.PR0EABS3 CAiBEThe crobable cause of this accident W failure of the pilot to recognize his proximity to the ground due to heavy Wlch entirely covered the terrain.by t:e board/.it/ Fred. A. Sssre w>ry Docket No. SA-93                                                                                                                                                                                                                                                                                                                                       File MoC I t I 1 A E R 0 H A U T I G S 3 C A R I)ACCIDENT INSTIGATION WORTAdopted.: April 6, 1945                                                                                                                                                                                                                             Released: April 11, 1945PAN AM-RICAN, LATIN A CAN DIVISION - August 3, 1944 *     *      i r i .          w                     r  L  "I *                                                                                                                                                                                                                                                                                                   * Flight 213 of Pan Americans Latin American Division, ~hile on regular Caribbean schedule en route from San Juan to Miami, crashedin an attempted take-off at Antilla, Cuba. Seventeen passengers were killed, nine of the passengers and all the five crew members survived.The accident occurred about l:20p,m. EFTT, August S, 1944, approximately a 1/2 mile southeast of Antilla, in Nips Bay.   The plane, a Sikorsky S42 .flying boat, made its take-off run, attaine   flying speed and became airborne. Immediately following this, the plane made tvo further contacts Tilth the water. Bron leaving the surface the  third time it gained an altitude of approximately 25 feet, then, dived a steeply into the water. The force of impact completely destroyed theairplane,From the evidence revealed bv the investigation. tht ^oard concluded *. -                                 ./that there was no mechanical, failure of an."' wart of the cimlane hut that 9 * the accident was caused b-r the faulty tech.niciue em.--lo-.red by the nilot, .and 1- - that such faulty technique was clue largely io his limited experience onthe particular type of airplane flown.This report was prepared from the facts revealed by the'Boards investi- gation'and the hearing which was held at Miami, Florida, August 22, 23 and 24, 1944.      From PilotManuals.com / RareAviation.com File No. 2667-44 NARRATIVE DESCRIPTION GF THE FLIGHT AT THE ACCIDENT. NO 823M left Miami for San Juan on August 7, designated as Flight 219, and was scheduled to return to Miami on the following day, designated as Flight 218a The flight was made via Antilla and Port au Prince with Captain Marion K; IVillians in command and with the same crew serving on both legs of the trip. The return trip from San Juan on August 8 -made th* intermediate stop at Port au Prince without incident. The plane arrived at Antilla at 12:43 p.m. and after a routine lay-over of 27 minutes, left the dock at 1:10 p.m., carrying 26 passengers and the five craw members. The.clearance records indicated that the aircraft was loaded to 17,090 kilos (37,683 lbs.) at the, time of take-off, which was within the allowable weight limits. A check of the distribution of load revealed that .the c.g. position of 31.8% M.A.C. was also within the permissible limits. . This was slightly at variance with the c.g. position cf 30.5% li.A.C. which  the-captain.had expected inasmuch as he had assumed that Compartments B, C and D would be occupied by eight persons each and Compartment A by two .persons. The steward, not being aware of this, allowed four passengers to  sit in the rearmost compartment (A) leaving two vacant seats in the foremost .compartment (D). This condition might have required a slightly greater nose-down position of the stabilizer but would not; affect the take-off. *****                           V At;about 1:18 p.m*, the pilot taxied to the-take-off position. The ^ weatherWas clear and the ceiling unlimited with a. wind estimated to.be :l20 knots from approximately 100. The water was choppy vith.noground- jSwellsy.v^ith a gradual opening, of the throttles to 332 inches of manifold ^pressure,. the plane appeared to go on the step normally and was making- . /approximately 75 knots.  The captain then requested an increase in manifold . ./pressure from 33| inches to 35 inches and upon attaining, a speed estimated . fas/between 78 and 80 knots, the plane left the surface of the water. Captain v^illiams stated that as the plane rose into the air to a height-of 10 or 12. f :-<;fset,he relaxed back pressure slightly, in order to gain speed, whereupon . ;the plane seemed to want to go back on the water so he pulled back on the ' / /.jyoke*?^en it became obvious to him that the plane was going to go back on ; "the'water, anyway, he dropped the nose quickly to "flatten out." After b striking,, bow first,- the plane left the water in a slightly nose-high .-attitude, rose higher than previously, then returned to the water at a A s^ch steeper angle. The third time, the.plane, rose out of control, to a height of .approximately 25 feet, and in a steeper angle of climb than ^previously*  It 'then nosed down at a.sharp angle and struck the water ^violently.?'.// .. .  '             :                       ?          :           . ..    *   X .**      *   (      *       **                             *                                                                                                                                                                                           ^^'^^The nose of the plane struck the water with such force as to cause the and completely separate at a point .just aft of the pilot's .i'cQj^rt^nt<\:'W                  the plane, -which included passenger com-j 1 partincnts A, B, C, and D, pitched, forward and came to rest in a nearly in- verted position vn.th the forvrard portion fully submerged. .///                      < -v                                                                                     1 'li EnsenadaLaraV4Bah t a         C o r o jat                                                                           ANTILLA                                                                       *O                                                                                      .* 4^1 D                                                                                     f.BahiaMa notioJ                                                             K EYAB     Line            of        take-off CD     Track followed by boat while                          aircraft was beingtaxied to point of take-off. DE         Path of boot to point E where it turned around and returned to Pan American dock. Bahia                  Nipe                                                                    Point of aircraft crash. GH     Landing path. Point boat was doing landing.J             Triangular track followed by boat during landing procedure* K            Points faster boats took off from.From Pilc^aM^G^i^ RareAviation.Gom                                   " File No. 2667-44  As it will be noted in the inserted harbor diagram, the station manager's view of the take-off was obscured by the dock. When he failed to receive an "off the water" radio report from the plane, he attempted to contact the flight but was unsuccessful. Shortly thereafter, an ob- server from the shore informed him by telephone that the plane was down in. the Bay. The station, manager immediately called the captain of the Porf for aid and two Peruvian torpedo boats proceeded, to the rescue, A . slow^speed,.non-radio equipped launch, temporarily being used by Pan American in plac.e of the regular boat which had been undergoing repair for approximately the past six months, started to the scene of the accident. When it became apparent to the pilot of the launch that the larger and taster Peruvian boats were under way, he turned back to the Pan American dock to take aboard additional -help  The crew, including the steward, who..was with the others in the pi- lot's compartment at the time of the crash, escaped'through the break in the hull and proceeded to help the passengers out of the wreckage. Of the r -six persons in the extreme forward 'compartment (D), four were rescued : although one of these succumbed a few minutes after being taken ashore. . None of the eight passengers in Compartment C survived. compartment B was occupied by eight passengers, -three of ?jhom survived the crash. The . . reargiost compartment (A) was occupied by four passengers, 'three of whom wpre rescued through; the-.entrance hatch on the-top of the hull.' .With the aircraft floating in an upside down position, this hatch'was submerged in the water and in order to escape from the cabin it ?-as necessarv to wo down into the water, through the hatch and up on the'.outside to'ths-Surface. The steward, an expert swimmer, entered the cabin through this hatch and was instrumental in bringing up the surviving Passengers.  THE BOARDS INVESTIGATION                             '/f'-;' /.' Investigation- Initiated -.   .         :               h < !'                "     .1 ? . -.Washington Office of.the Civil Aeronautics Board received . notification of the accident about 3:55 -p.re.-, August 8, 1944,-and immediately initiated an investigation in. accordance with the provisions of Section 702 (a) C2). of. the Civil Aeronautics Act of 1938, as amended. iredG. Powell Senior Air Safety Investigator in-charge of- the Atlanta,. Georgia Office of the Board, arrived: at AntiUa at 3:30 p;in/j Autist 9 drid found that'the wreckage had been towed to .shallow watdr near the Ant ilia dock and 'that the bodies of the victims had been removed. On August 10 salvage operations . }aegan and the. wreckage. was.,removed from the water to the dock, placed upon railway flat cars and,: transported, to the pan American Base in Ant ilia, h . -' i-z where it.was.placed .under guard, awaiting'later examinetion. On August 12. William- K, Andrews, Chief,, Investigation Section,"and W.' S.. Kbnecznv, -'0 Aircraft 'Specialist, both; of .thg;Safety:-.BUreau of the Board/ arrived from < Washington, D. C.:-tp assist Powell .inimking-the/investigatioii..-        : File No. 2667-44fearingThe Board ordered a public hearing which was held August 22 to 24, inclusive, at the Dade County Courthouse, Miami, Florida,, with VJ. K.Andrews as presiding officer. In addition, the following members of the Safety Bureaus staff participated: J. W. Lankford, Director of the Safety Bureau; J. K. Fenno, Chief, Investigation Division; . F, G, Powell  W. E Koneczny, and R. P. Parshall, a Senior Air Safety Investigator of the Boards Kansas City Office,SUMMARY AND ANALYSIS OF THE EVIDENCEAir Carrier Certification Status-time- of . the accident Pan American Airways, a New York corpo- ' . Rationy;;Was operating as ari carrier under a certificate of'publicand an air carrier operating certificate, both /;pursuant to the Civil Aeronautics Act of 1938, as amended.' These authorized the corporation to engage in-transporting- by air, i.?JasenS^rsj property and mail between the United States, its territories,, -ind foreign                             Florida; Antilia, Cuba; Port au .Prince-,' Haiti; and San Juan, Puerto Rico.218 consisted; of Marion Koonce Williams, * cs^taih; JV first officer; Elijah W. Beasley, flight engineer! radio operator;; and jfiaymond; D. Whitmarsh, Jr* / steward;Captain Lillians, age 27, of Miami, held ar. airline transport pilot -fjcerbificate, with a multi-engine sea, 650-4500 h.p. rating. At the time M16 accident he had accumulated as a student, first officer and captain .  a ^^al .f 1523 hours of flying time, of which 1017, hours were boat time. A;? a boat captain was 661 hours of which 82 hours were on S42 flying boats. His last physical examination, required by the .Civil Air  . Regulations, was accomplished February 10, 1944. He. had been employed by Pan Afficrican fr three years. He was route checked iri an 42.in Mayl944 '' ' W first trip in command of an.S42 on June 3, 1944, approximately                                                                                                                                                                                                                                                                                                                           1 , .55 : two months before the time of the accident-                     - '  - R-wfe/  _.c-*                                                                                                                                                                                                                                                 '  '  . -  . . .  .                        - r r  --  < t                                                                                                                                       ' -.    - * 1 -                  ,  -  .                        - .                                              -  - . 1 *                        , -      V                 -       -     .  .                .                                                                                                                                                '                        a         -Vi*                             . -             -              .                                                                      '                                                                                  "                    1                          -                                                .                    a WS- First Officer Publipker,: age 22, . ofhad' been employedby Pan American for one'year. '                                                                                                                                                                                                                                                                     He held a conmercial pilot certificate with 90^270 h.p. and instrument ratings, and had J <1^                     His expepiehcb/incliK^                     .The snbjct ^riP was his first vd^bROhptai^/^ilia^ :7; examination,'required by the Civil: Air Regulh^tibbsy *^as' acccmiplished ; April 18, 1944.                                             . '    :              -      ' < -''UFrom Pirc^iyrahu^s.cbrrtV K'areAvt^onxo^                                                                                                                                                                                                                                                                                                                                               v-7  V *.               1                  I                                              -                      .                                                                                                                                                                                             1.-  File No. 2667* * *44 Flight Mechanic Beasley, age 30, of Miami, held an aircraft and engine mechanic certificate, and had been employed by pan American since February 1942. He made .his first trip as flight engineer , on an S42 on June 10, 1944. -                                                                     " *   Radio Operator Chapman, age 19,/of Coconut Grove, Floridaheld a second class radiotelephone and second: class radiotelegraph operator's certificate. He had been with Pan American for two years. -     ' /;- Steward Whitmarsh, age 31, of Miami,had been in-the employ of Pah.: 7* American since May 1943- He had previously been a Red Cross life saving -. .  examiner.                                                 -                                  . The Aircraft  NC 823M, a 34-place Sikorsky S42 flying boat, serial number 4201, ' was manufactured in 1934 and had been flown a total of 12,389 hours *       It had seats-for six crew members and 28 passengers. It was equipped with four Pratt & Whitney S1E*G Hornet engines. Its rated cargo capacity was 3546 kilos (7820 lbs.), useful load 6240 kilos (12,848 lbs.) and- maximum authorized landing weight 17,237 kilos (38,000 lbs). A 150-hour check had been made on the plane August 6, 1944.                           Examination of the Wreckage                                                  -  * . *  *  The examination of the wreckage was made by W; E. Koncczhy and Fred G. Powell of the Board's Safety Bureau.-. They were assisted by Paul Reimer,// Assistant DivisionEngineer for pan American in Miami ; JeronKj/AnriiSy: Senior Air Carrier Maintenance Inspector: of the-Civil Aeronautics :/ ;     . Administration; and Captain H. J. Chase from Pan American's New York       / headquarters.                               ..              : ' -                  :-?/-  * * .   Ninety-five percent of the airplane wreckage w estimated to have- ' - been recovered from the Bay. After a thorough examination of all the parts, no evidence was found to indicate any mechanical failure of the aircraft prior to impact, which could conceivably have been responsible for the accident.                                             The hull was found in two sections, the larger consisting of the portion from the stern to and including the rear wing strut attachment.- station; the smaller section consisting of the bow and extending back as far as the aft bulkhead of the pilot 's compartment. The .area between these two sections of the hull, comprised mainly of the mail conpartment, was badly broken up and parts of the structure were missing completely. The deformation of the bottom and the bulkheads in this area indicated the bow and the stern had been forced upward with relation to the point of fracture and separation. The sections of the hull were held together in the water by numerous.-. cables which subsequently had to be Out in 'order to facilitate salvage operations.5. - I  /; /. The wing failed at a'point between the tower (cabane) and the starboard, inboard engine. ..This section of the wing-separated completely from the . main part.of the wreckage and remained relatively intact vrith its two engines attached. Some question arose during the investigation regarding the amount of flap used during the take-off, therefore the flaps wore ii.ven exhia.uES'tive fstxiciy. Portions of the flap surface were attached to their respective portions of the wing. The starboard part of ths flap was free to move but the. port side was. jammed in the full-up position. ,V: This in itself is not significant inasmuch as in all probability the : hydraulic lines would be severed on impact, allowing the flaps to  change their original position. Examination of                                   the contacting surfaces " of the flap and.the wing proper did not reveal,                                 with any degree of certainty,, the position of the flap at the time of the accident.In order to obtain a more thorough examination of the hydraulic .. flap rams, these parts were forwarded to the National Bureau of Standards. The tests conducted by the Bureau of Standards, for the purpose of i. establishing from local distortions, the position of the pistons, did not result.-in apositive determination of the flap position. It might appear from she Way the .airplane is said to have performed that the flap was retracted at the time of take-off;. however, in view of the lack of evidence to the contrary, it must be assumed that it was properly extended and functioned normally at the time of the accident. /The tail assembly, although damaged cons Iderably3 appeared to have revived ^Kjst .-pf its .damage .through salvage operations. Consideration was . . to^                 an erroneous -setting of the stabilizer by either^  of. thQ/^                   yras not- possible to establish, the position-of the stabiilzQi* ai\ the .time of- the-.accident, with any-.degree of accuracy^./... - inashnuc^                   and the .indicator mechanism probably was affected byimpact'Jc^pes, all evidence .indicates that the stabilizer was set-at a \ ; sligb^^            position,- which would have been normal in this instance-.' Ah/^             the .-stabilizer- mechanism revealed that, there  had been, a / -sligh^              of "the .stops which limited its extreme nose---down -. have allowed the.- worm strut to bind at its. upper end. ' -is not believed to have affected the proper .control the-plane fat: the time of-the accident.StatementsJ ;?;Ac<jb^cirrg-.to: the testimony of Captain Williams,                     everyrning functioned norMlly during his taxiing out to the take-off area                     with theexception. .. of the inboard; engines which tended to heat,                         This was corrected by use                               IF                     ofthe/o^               ...-Wile taxiing.to the take-off position the , captain asked for and received an indicated 10 of flap.       "    . J   i*           *\ 1 I .. *  *. 4.       _                               **-*                              ;                                                                    v.Upon reaching the take-off Area the plane'ms headed, into the -wind i.. and the take-off was started. After applying 33J inches of manifold/pressure the thr ottles, were turned over to the flight ..engineer < The plane? canie up on the step in a normal manner and had attained a speed of 75 knots, but due to the choppy condition, of the water, the captain asked for and 'From dais: corn;/,-:Ra re-Avi a&QnebfT). .                             File No. -2667-44  received 3$ inches of manifold pressure. The airspeed immediatelyincreased to between 78 and 80 knots, at vzhich time he applied back pressure and the plane became airborne. He stated that he did not "pull the plane off" but "merely helped it off." Then in order to gain airspeed he released the back pressure on the yoke, whereupon the plane seemed to want to go back on the water, so he pulled back on the yoke. Seeing that on the water in spite of the back pressure, he quickly attempted to "flatten it out" by a slight forward pressure on the yoke. After contact with the water the plane came off but was not in an extremely nose-high postion. However, the airspeed had dropped to 75 knots A                 peak of this bounce, the plane started back on the water - and this time he pulled.the yoke'all the way back. The plane hit the water m a slightly nose-down attitude, at which time, according to the captainhe had lost all control of the airplane. It left the water a third time and after attaining an altitude of 25 feet, dived steeply and struck the water violently. The throttles were not cut at any time. The testimony of the other crew members was almost identical in every respect with that of the captain. None of the crew had observed the wing to note the actual. flap position. They stated that during the successive contacts with the water the wing remained lateral and that they had no particular apprehension even after the second bounce. The captain and the first officer testified that they had gone through the cockpit check-off list individually instead of calling it out verbally as required by company procedure.                         ; ' / [ The passengers testimony was in full agreement with that of the-::: :     s? crew and revealed no additional facts. *                                .*                                               *     **                                                                              * I         *_        X *       * It was stated by qualified pilot personnel that the airplane having - ; attained an airspeed of 80 knots, was fully airborne when itfirst left the water and that even had it been pulled off the water, at a somewhat lower speed, its flight Characteristics would not have been critical. Further testimony brought out that the best recommended procedure for .  ? recovery from maneuvers, such as the airplane was experiencing, is to  - "cut the power at such time as the aircraft is on the water, in order that a stable angle of trim may be resumed as quickly as possible. Normally this is attained by full reduction of power at the time the aircraft touches the water."FINDINGSOn the basis of all the evidence available to the Board at this time the facts relating to the accident are as follows:                       aircraft was being operated under proper certification and had been adequately maintained, with the minor exception of the stabilizer adjustment, according to CAA requirements at the time of the accident. v;File ho  2667---4'4' There was no evidence of mechanical failure of any part of tTie aircraft                                                prior to impact.  *..   . Jhe caPtain as^d for and received the proper flap setting prior', vo the attempted take-off.                                        had attained flying speed and become airborne. i  ---   i|i                                      a    w                                  *                     *                   -                  .     4         1            .                     * Plane became ^i^borne, it was allowed to settle back ;-after bouncesthe pilot -compiletely lost control-    -                                             -r                                       1  captain Williams; held proper CAA certifi                                                                                                                                                         czrtes and had more 'tlxan W.necessary experience to meet general minimum                                                                                                                                                                                                                                                                                                                                                                                                                                                                      requirements; however, lt; ':s evident from his record that his                                                                                                                                                                                                                                                                                                                                                                                                                                                            experience a. 5 captain on this siz ertreBely      --        -x~. yj. g . e easley also were relatively inexperienced on S42 eqnipidieiit. of a ^iii+a'hi y---ri launch being used at the time of the accident was not 01 a suitable type nor was it properly equipped, a t a a                                                                                                                                                                                                               r                                                                                                                                                                                                                                                                                                                                                 IDISCUSSION AMD CONCLUSIONSfroin + 6klnVeSfF7n revealed nothing in the conduct of the flight .kSw tn SOf 15F^ar the tine of t}ie Planehs leavi^ the . ; kCSpise: ;of; iha; a'cciSnt a e~ / frc>B1 Anti?-la> which would indicate a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           s. a aw .                                      >                                                                                                                                                                                                                                                                                                                               .                                                                                                                                                                                                                                     -I                     VfIiWe*to^omJ) cha5^tJi2^d this flight as vnag '                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 :a pi*o.cedu^^^       the- iaok nf  comply_TO.oh the proper cockoit checlc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              X ^standing.between the crew members 1st s sin 'the'                   ^ignif loanee st be attached to Captain XlliaiftS r OTV'Ti fliS and M?ine tro is during the arampueq taxe-off and subsequent maneuvers of the a-frc-aft this invettigation, it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     xn t>heiAirplane first returned to the water <d ^6^1 effeCed at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   5#Theee ^ne in all probability             ?XXtP ^experience ].n. handling S42's.                  J pilotX{.&8 7?^File Jfo . 2667-44HJDBABIE CAUSEoontrolXX^kSw^ T* te6Bgh 11,13 litigation, loas of ng - - off vras found to be the probable cause of the accident. BY THE CrZIL AERONAUTICS BOARD:. /s/ I> Welch Pogue L. Welch Pogue/s/ Edward Warner Edward Harner/s/ Harllee Branch Harllee Branch/s/ 0 sv7ald Ryan Os'.Tald Hyan /s/ Josh Lee Josh Leen-7'i S'                                                                                                                                                             I                                                                                    / . .                      '           J- M \-                                                                                                                           *                            -I  Docket No. SA-99                                             File No. 98-45 CIVIL A E R 0 N A IJ T I G S B 0 A R DACC IDENT INVEST IGAT ION REPORTAdopted; April 19                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Released; April 24, 1946PAN AMERICAN, LATIN AMERICAN DIVISION, TRINIDAD, BRITISH WEST INDIESJANUARY 8, 1945The AccidentPan Americans                                                                                                                                                                             Flight 161 of its Latin American Division, en route from                                                                                                                                                                                                                               a  r                                                                                                                                                                                                                                     l                                                                                                                                                Miami,. Florida,, to                                                                                                                                                                           Leopoldville^ Belgian Congo, Africa, crashed during a night  * -  . <  ;  .  landing at Port of                                                                                                                                                                             Spain, Trinidad, B.N.I.. at 2116 January 8, 1945 Thsaccident resulted in fatal injuries to 23 of the 30 occupants j- injuries to r                                                                                                                                                                                                                                                                                                                                                                                                                                                                              those surviving, and complete loss of the Martin LM30 flying boat.Description of the Flight;  - Flight 161 departed Miami Florida, at 0608^ January 8, and landed without incident at San Juan Harbor, Puerto Rico, at approximately 1423.-    4                                                                                                              a After refueling and routine mechanical check, Flight 161 took off from San '.V -        Juan, at 1605 on a contact flight clearance for Port of Spain* Trinidad, theT' '    || V                               - r'                      next scheduled stop* . Routine position reports were, made at proper intervals  --- M   * and at 1930 the flight received a company message reporting.satisfactory *  contact weather at Port of Spain,.  Approaching Trinidad, the plane was being flown from the left Pilotos . seat by Captain, L# Cramer (serving as First Officer pi the flight) withCaptain C. A*. Goyette (in command) in the. co---pilota seat on the right.   * Approximately 10 miles from .the-north coast, of Trinidad .Goyette-.instructed _       Cramer.-to remain in the. left -seat and to make the .approach and landing at Port * *  ' of - Spain*.. -                                                                     -. Crossing the north coast of Trinidad at an altitude of 4,000 feet, a .gradual lot-dovm was started*. The Port of Spain company station then advised.IK f & vt the wind was calr., that lights to mark the -lancting area, oh ^t^/Surfdee .of the water were l&id out. on a .70^ course,- that no traffic wa s /e area, and that it was cleared to contact the company service launch _ _______ if ---r---.    ---------- -------* ** ---' *  2109,. Flight 161. was advised, "nc traffic, vou. are number one to land .Corcorite area/1 Cramer continued his course over the row of lights \ *                                                     \* *****                  *   *  and made a turn into the right-hand traffic pattern. Inasmuch as the plane's was to- hi5h for. the final approach, Goyette advised Cramer that it r.:V*. < ?          -*s   J -             L                          2        *.*.           . ' *'V?: would be                                                                                          necessary to circle the landing area again. Cramer complied, passed <W?                                                                                                                    ** *    _<  *               7?;s over the                                                                                            landing area a second time and started another                                            360 turn, this/time ithen advised Cramer that, because                                                                                           of adjacent hills : '</ :  - ;  .-** ' ( %  r  *..    (      & left-hand pattern was not desirable and Cramer turned                                                                                                               into the.right-hand pattern. This downwind course was continued fos minutes beyond the No. 1 landing area light. A 180 turn for the final-approach placed the plane at  *<       "    * approximately 3 miles from the IJo. 1 light at an altitude of about 1,000 feet/ of Capt... Goyette, a final approach was /?-P? descent of 600 feet per minute and an airspeed of 5knotty. At an altitude of 800 feet the rate of descent was reduced to 7? about 300 feet per minute with the airspeed remaining between 100 and 105 / :: When approximately 700 feet above the surface the left landing 'light was turned the servico launch was advised that the flight was on final approach. y                  -ol about 400 feet a light haze wat encountered which Captain  //^i^                     affect the visibility- ' about 3Oo//7; t jnahl>oidfpressure ms reduced- fr^O to 1g: inches 17 acbor^?/j // at this tinej^-: aitcreft as about 3/^: nii^ fi-om'^he No' l-Iigh^M approxinately il5 j^ics per hdur< 7       - .- 1 . > . . < He also stated that at an indicated altitude of 250 feet with airspeed                                                    *                       i I                                                                                                                                                                                                *                                                                        at 100 knots, he called out these, readings to Cramer. Soon thereafter, Goyette, whose attention was still focused in the cockpit, heard what he                                                                                                                                                                                                                                                                                                                                                                                                                                               a described as a "tearing, shearing" noise, followed by a sudden lurch. As the plane came to an abrupt stop in the ;vater, the hull broke in. two at a point * < about three feet aft of the hull step (about the center of compartment 2) and  <  the rear part of the .-hull was forced up and forward. Water poured into the - cabin and major portion of the flying boat sank immediately. ' Certain partsof the wreckage remained afloat for a short period while rescue work v/as  conducted by. company service launches and Navy rescue and salvage units .                                                                                                                                                                                                                                                                                                                                                                                                                                              4 The point at which the'wreckage sank was miles short of the No. -1 light *  which marked the nearest portion of the intended- landing area.InvestigationDuring the investigation the surviving three crew manbers and .four "    !passengers described their impressions of the crash. Captain Goyette,  I                                                                                                                                                                        seated in the righthand pilots seat, stated that the "tearing, shearing" noise emanated from a point forward of him, lasted several seconds, and                                                                                                                                                       I         1 .     was followed by a "quavering" motion and impact. During this time both '                                       *                                    B                                          4                                                                                                                                                                 Goyette and Cramer were forced forward in their seats                                                                                                                                                                                                                                                                                                                                                                                                                                                                Third Officer     S. K. George III, seated, and facing aft in compartment 3, said that there    was no shock or jar prior to contacting the water, and the sound of contact . was deeper than usual and was followed by a violent lurch. He was thrown backwards toward.the front of the ,cabin. Acting Flight Engineer J. W, Horse,.  seated, on the left side .of compartment 2 facing forward, had been in the .  -  t -  flight compartment prior to the approach and noted that the Indications of the 3 airspeed instruments of the pilot, co-pilot and navigator corresponded.From PHbtManuafs.cQm /RareAviation;coot - .         I -                                 *                                        When at an altitude of 40 or 50 feet, Morse noted from his scat in compartment 2 that the left landing light clearly illuminated the surface of the water which vras rippled. He further stated that the upper surface of the left sea- wing seemed parallel with the water surface. (This portion of the sea-wing is at a 5-dcgree up-angle from the keel). Morse's sensation was "momentarily of a normal landing", the plane then lurching violently and stopping abruptly. Passenger C, D. Williams> facing forward in compartment 3, stated that the plane seemed to "settle" just before the crash and that he did not recall                                                                             * *  * .  >  any prior shock or noise. Passenger E. A. Prado, facing forward in the -  lounge/ observed that the plane was very Ioyj for an appreciable period of ... time and he noticed several  os dilations which v/ere followed by the sudden shock of the crash. Passenger A. S. Mackey, also facing forward in compart- ment 3/ recalled nothing prior to finding himself in the water. The fourth.- surviving passenger was a 7-year old girl. .                           ' ' .                        4 4     <                                       *                                           *                                  < .In analyzing the statements of the survivors, it is apparent that the /                        5                                                               t                                                                                                                                                                                                                                                                                 *                                  *                 aircrafts keel first contacted the water at a point well forward,, near the 7  bow, while the plane was in a slightly nose--- down attitude. Goyette stated I .                                                                                                                           .                                                    *     *         * '         that the initial sound of contact emanated forward of the pilots compart- /              <        *                                                4        ** ment. Morse1s statement suggests a 5-degree nose-down or approach attitude/{. Considerable sound-absorbing material between the crew and passenger coin- partments might account for the passengers not having noted the ripping^//-/-, tearing noise as heard by Goyette and George. - Although George was seated in. compartment 3 and heard such a noise, tliis is accounted for by his normal /                                                                                                                                                                                                             .                                                                                                                                  *       * *  f   *     anticipation as an airman in listening for the first sound of surface contact/ - . :    .     '  :    Seven lights, marking the landing-area, were anchored in a straight//;./^ line on a bearing of 70 degrees. The distance from No. 1, on the approach/?? :. -=&&&      ; end, to No. 2 was 1500 feet. Others up to No. 6 were 750 feet apart. No. 7 r was 3,000 feet  beyond*-No. 6 and marked the extreme limits of the ?. vailablelanding area totaling 7500 feet in length. These lights were of a fluorescent  --- type and are considered to be highly satisfactory for night landings during                                                                                                                                                                                                                                                                           w I normal weather conditions. No weather handicaps prevailed during the approach or landing. Visibility was unlimitedWitnesses to the approach who were on the company service launches asaw a single landing light approach with uniform and even descent until                                                                                                                                                                                                                                                                               -                         J"                                                                                                                                                                        I it appeared to be at water level when it suddenly went out. Company  *                                                                                                                                                                                                                     SB                                                                                                                                                                    procedure provides that when the second landing light is turned on during *                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    a                       *                     a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        the approach it constitutes a signal for the firing of a flare from the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   I I                                                                                                                                                                                                                                                                                                                                                                                                  I            company launch as an aid to the pilot in gauging accurately his height a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         a above the water. In this instance, the pilot did not turn on the second   t                                                                                                                                                                                         *               * landing light during his approach. I                                                                                                                                                                                                                                                                                                                                                                                                                              M Examination of the wreckage revealed no indication of malfunctioning of any part of the airplane prior to its . impact with the waterr Both vangs were broken off; the; left v/ing and left sea-wng received more damage than  .                                                                                                                                                                                             *                                                                                                                                                                                                                                                                                                                                                                                                                                                                               a those on thd right.  The hull was broken in two at the center'of No."'2                                                      a        compartment, approximately 3 feet aft1 of'the hull step.  The f-ori-vard .portion' ; .                                                                   -                                                                                                                                                                                        - J                                                                                                                              -                                              *                                                                                                                                                                                                                                                                             ,                                                                                                 *                                                                                                              -                    - of the hull was badly damaged, the rear portion was buckled arid- forced _ --- _ ---  . in ah upward direction, and.the extreme rear section of the hull received                                                                                                                                                                                                                                                                                          a                                                                                                                                                                                                                                                                                                                                                                                                  a                    ok                                                                                                                    . little damage. . Approximately 400 square feet of the hull bottom was not recovered. .This .section of the bottom covered an area from a point 'a. few. feet aft of the bow to the region of the step, the hull skin having fn.il predominantly in an outward direction. ; The left altimeter setting was found; to be very close to the then                                                          *                                                            I                                    *                                                                                                                                                                                                                                                                                                                          *           r I                                         4 * - j                                                                           I                              . e 1       -     1                       1                                                                                                                                           t                                                                F                                                                           ,                               -                                                                                                                               -                              i existing station pressure of 1014.6 millibars. The right altimeter, from ; y which Captain                      the altitude of 250 feet4 was found set at i                                                                                                                                                                                                                                                                I* 1014.2 Millibars, a discrepancy between the two altimeters amounting to 'Wm* only 11 feet in altitude. The Kollsman repeating compasses on the instruM panel wore found set at 77 magnetic, or 70 true, the bearing of the line^ lights at the landing area, ; ;i SThe aircraft was equipped with an NACA V-G recorder, the purpose of which is to record vertical acceleration in relation to speed. This recorder was recovered from the wreckage and a detailed discussion of the results O obtained from a study of the recording is included herewith as Appendix I, & In brief, the V-G record, as well as the condition of the bottom of the hull ' as described above, indicated that: (1) the aircraft contacted the surface of the water at a higher than normal landing speed, and (2) the impact occurred while the aircraft was in a nose-down attitude.                    I During the salvage operations there were found in various places small f particles of wood, oakum, and paint chips. Inasmuch as the presence of thi-^f material within the ..wreckage suggested a possibility of collision with scree wooden vessel or object, specimens were referred to the Federal Bureau of    * ***,**    ** Investigation, together with samples of wood and paint from the U, S. Navy salvage boats and from the piling and pier at the docksite where the wreck- age was finally placed. Examination by that agency revealed that these various articles corresponded to the materials of the salvage boats or the  . " - docksite, thus eliminating the probability of the planes having collided with any such object prior to impact with the water. Examination of the   - - -? wreckage revealed no evidence of collision with any object either in the air or on the surface of the viator; .  -                   ....   ' ; Captain Goyetce wc.s an experienced, pilot with an accumulated total of ..about. 7040 ,f lying hoursr He had served, nine years -..-with Pan American the time of the accident.was rated by the. company as Faster Pilot. Although :     : -                              - 6>-                                      . ..                        ' LGoyette had flown Martin M-130 aircraft a total of approximately 1560 hours5                   a             a   he had never made a night landing in that type of aircraft at Port of Spain. Moreover, for at least two years and two months prior to the accident, I                                                                          V                                                                                                                                                                                                                                       Goyette, had acted in the capacity of assistant chief pilot in charge of  personnelj and although his duties included that of check pilot he was not a                                                                                                                                                                                                                                    a a regular pilot on. scheduled trips between Miami and Port of Spain at the r  time. However, Captain Goyette had made the proving run over this route three        1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       months prior to the accident to the satisfaction of a CAA Air Carrier Inspector   *   and had since that time completed two additional flights. His wide experience in flying boat operation in addition to his familiarity over the route leaves> no doubt that Goyette was qualified to serve as captain of this flight.                                                                                                       I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ft Captain Cramer's flying experience totaled approximately 7034 hours of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        I   * r which about 882 hours were flown in Sikorsky S-42 four-engine seaplanes. His l                                                                                                                                                                                                                                                               .                                            employment with Pan American dated from April 1, 1942, and he had served as co-  **   pilot and then as captain in the company's Eastern Division. The subject trip was the first flight made by Cramer over this route. Cramer had been checked                                                                                                                                                                                 I                                                    *                                                                out by the company in the Martin M-1J0 type aircraft three days before the departure of Flight 161, and this flying time, with the addition of his for a portion of the flight from Miami to Port of Spain, constituted his total ?  * w  *  flying experience in an M-130, The company check flights in the JI-130 included night landings but vdthout cargo or passengers. Cramer' s pilot certificate required him to wear corrective lenses when piloting, but he was not wearing ! glasses at the time of the accident., Discussion:                <                                                  . 11              * * 1 1 1. ' ---   "   Statements of the surviving occupants of the aircraft, examination of the damaged hull, and the record inscribed by the HAGA. V-G recorder leave little ddilbt that the Ife^jn. ii-^ljd first contacted the water at more, than normal. . . ^hding speed and in ^n .^cess              attitude  Forces created by the' -  d ,;7speed of the aircraft in the nose-down attitude on its contact with the caused failure of the hull bottom and its structure, resulting in rapidncrsion.                                                                                                                                                                                                      I Landing of the aircraft on the surface of the water in the attitude indicated, and under the then existing conditions of water surface and ; mis judged his true ; *. weather, v.as undoubtedly due to the pilot                                                                                                                                                                    m r<-* ?' ,>v: altitude above the surface prior to con                                                                                              the wat-oi                           cl his failure W? * to correct the attitude fci,anormal lanci.i.r-g ft the prop                                                                                                       woraeht..        It                                                                                                                                                           sur$kcc of veryis clifficuJ.i to judge altitude, proci scly above the                                                  of glassy rater-'Ad smooth                                                     glascy water. There is a possibility that patchesexisted                                                       at the time of the accident inasmuch as light winds prevailed arid 'th^: '  . ..  ,                                                                                                                                                                          a condition conducive tdWJ landing area was on tho lee side of hilly terrain                                                                                                                                                              - . ; 'i<W \  , /  smooth water, However one occupant of the aircraft noted just prior tc the y    I                        * *                                        landing'that the surface ms rippled, .'ith the                                                                                                         ssistance cf some rippled p  S F            %**             *                                                                                                                                                        *    '?  .M  * --- i                                      .^A v*ri water and the row of lights  marking the landing area                                                                                                                                         it should not have been *   ..... difficult for pilots seasoned in seaplane operations                                                                                                                             as v.ere both 'Goyetteand Cramer, to have effected a norsnland smooth landingIn view of the fact that the rate of descent and airsoccd of the aircr^i  .during approach were net unusual and inasmuch ae:thv accident occurred; . short of the first light, it is apparent that the approach was begun  I ***. 4.                                                          .                                           " .great a distance fresa the landing area. Approach from an altitude of 1,003? ..             ....                                                     ' '                         ..--<.'^-^^10 feet but at ah excessive distance from the landing area would reduce from which the row of lights was viewed by the pilots. The practice such landing area lights as hereinbefore described is to assist the?pa4|^^pi gauging more accurately his altitude above the surface and distance frdmSintended point of. landing. Reduction of the angle of. view of these liKh||                                                                                                                                        1 .1the pilot's judgment of distance more difficult. , VPnen presumably;at <m- tude of 300 feet, Goyettq. mis judged the. aircraft's position asrNo                                                                                       1- light.Statements from the. company doctor indicated-that Cramers visual, defect - -                                                              ,                         .                     r                 a                                          a                                                                                                            - lwas                                                                                      of a .mild nature and that under the conditions that then existed he shouldhave been able to see the entire landing path without difficulty. ' CAA medichi/f/ examiners found the. above statements to b consistent with the medical reports--concerning Cramer contained within CAA records for tho                                                preceding five years/However, in.view of the fact that his vision without glasses.was inferior<:<  * " to that normally required of an airline transport pilot, his failure to wear                                                               * 1 a                                                                                                                                                                                                                  I                                                                                                                                                                                                                                                                      r 9                                                                                                                    '                                                                              - glasses cannot be dismissed entirely and may have contributed, to his errorI                                                                 "                                              .1    * in judgment of correct altitude just prior to impact. I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            I                                                                                                                                                                                                                                                                                                                                                                                                                                   fc                                                                                                                                                                   .                                                            Knowledge of Cramers, considerable previous experience with.-four- /. engine flying, boats would have .justified Captain Goyette in assuming that- U':.<                                            '                                           '            .                                                                           ,  WS caPable of .negotiating the landing safely;.and, therefore, ': . Captain Goyette is not subject, to criticism for directing First Officerr,              a                                                   **                                     -           **"                 a       *        -                           a               -     *                             * J* *           1           *                    r                                                        _                        I                      "                                                 -        -                                                           a. | Cramer to execute the approach and.landing. However, since. Cramers totala*                             a                            a                                                                            *                                                      --- ;ejqjenence, in the. Ihrtin S^ISO type included: less than a. two-hour h^ipaij  y^_eheck-out at  Miami and a  portion of -the flight time - to-Port .of Spain,   ? /.Captain. Goyette should have been .particularly' alert to his responsibility/: that the aircraft be landed -safely. Proper exercise of this                 -                                                        I       -   - r e sp on s i b i 1 i ty .                                                                               -                                             -                  "l                                                                             . .                     - '    ... *  required a greater attention to the attitude of. the aircraft aud-                its relation *           ww        _-a   a  paB                        * bha^-; -:t0 .any particular instrument indications..   a                             The                                                                             statement  -.' J   -  --           *                                                                 .                                                                                                                             -                     .                                                                                                                                                                                                                                                                                                                                                                                                                             * .. .^                        that his attention was still in the t           i 51 - - CCCKOlt^4prihg the. final stages' of the..landing indicates-his-preoccupation/%rith''a-nb ailure at the crucial moment -ad^quatDiiy7.tb.->ifeilt.6jij                     a             a                                           |                                                     a               a                                                                                                                                                               * dfc 59Piio^s; apptbath- to' d safe; .land 9From              ;                      * < . z *        *                      1                    '  -                 - : A-                                                                                                                                                                                                                                                                            is..... Upon the basis of all available evidence, the Beard finds that: The carrier> aircraft and pilots were properly certificated                                                                                                                                                        A-.' 4^5Captain Cramer, having very limited flight time in the aircraft, ;'7|  * *> ****  * *  % * was at the controls with Captain Goyette acting in a supervisory capacity.Conditions of weather and water surface within the vicinity of Port of: Spain were satisfactory for a safe approach and landing'   *  Ths: plane first contacted the water at more than normal landing *    speed and in a nose-low attitude. The crash occurred at a point 1 miles short of the intendedareaForces : created by the speed of the plane on its contact with  *   in the excessive nose-down attitude caused failure of the hulland,:its structure,  resulting in rapid subversion of the aircraftLanding of the aircraft -in the attitude indicated, under the thenexisting conditions of -water surface and weather, was due to Cran^r,s    r                                  .               *,**                                            *     *        *        _                         *   *             r  *    *       *>,         *                   |     *   having misjudged his true altitude and his failure to                                                                                                                                                            correct hisattitude for a norm! landingAtptfhe time of the accident Captain Cramer was not wearing glassesasrequired by his .-pilot certifi cateiVi.                                                         Captain Goyette, in command of the aircraft and with full knowledge  e A J.                                                            of.;CranErs limited experience in the Martin M-130, failed to exercisesufficient , supervision -of' the landingblei CausesW& 'On ^hG basis of the above findings, the Board                                                                                                                determines that the .7*5.-:             ?                           :                 y_.   v.-- .<  TOs -thrirst Officer Cramer's failure 7-.- ?!                                          ----A-                                           -.'=< :<-X.                        _ ; <:                                                               .the r  dr a                                                            i resulting in the inadvertent flight into the water in excess of normallanding speed, and in a nose-down attitude.BY THE- CIVIL AERONAUTICS BOARD:/s/ L. WELCH POGUE/s/ OSWALD RYAN/s/ HAELLEE BRA?fCH/s/ JOSH LEE/s/ CLARBHCE H, YOUNGSUPPLEMENTAL DATAInvestigation and Hearing The Atlanta Office of the Civil Aeronautics Board received notification at 2320 on January 8, 1945, and the Board initiated an investigation in accordance with the provisions of Section 702 (a) (2) of the amended Civil Aeronautics Act of 1938. The Senior Air Safety Investigator in  charge of the Atlanta Office proceeded to Port of Spain, arriving there about 2045. on January 10, and started the investigation. Other members of the Boards Safety Bureau staff arrived shortly thereafter. In connection with the investigation the Beard ordered a Public Hearing in which the Chief of the Investigation. Section served as Presiding Officer with others of the Boards Safety Bureau staff participating. The hearing was held at Miami, Florida, on January 29, 30 and 31, 1945. Air Carrier Pan American Airways, a New York Corporation with headquarters in New York and its Latin American Division offices in Miami, was operating at the time of the accident as an air carrier under a currently effective certificate of public convenience and necessity and an air carrier operating certificate. These certificates authorized it to transport persons, property and mail between various points, including Miami, Florida; San Juan, Puerto Rico; and Port of Spain, Trinidad, B.J.I. Aircraft Aircraft KC 14716, a Martin M-130, was purchased new by Pan American in Ocuooer, 1935. The aircraft was transferred to the United States Navy during the early part of the war and Pan American reacquired it on October 13, 1943  It ms powered by four Pratt and Biitney S2A.5G engines x equipped with Hamilton Standard constant speed propellers. At the time of the accident, the aircraft had been flown a total of20,545 hours. The airplane and. its equipment had been given a preflight inspection immediately prior to departure from Miami, It was loaded with its center of gravity at 33*4% of the mean aerodynamic chord which ms within the acceptable limits. The total weight upon take-off from SanJuan was 21,198 kgs                                  (46,720 lbs.), which was within approved limits.The airplane ms properly certificated and in an airworthy conditionwhen it was dispatched from Miami, Florida,                                   on January 8, 1945.Flight Personnel       |    |<               ! fiThe pilots on duty at the time of the accident were Captain Cyril Adrian Goyette, age 35 j of Coral Gables, Florida, and First Officer Leonard ./right Cramer, age 38, of Miami, Florida, First Officer Cramer, who was at the controls at the time of the landing, did not survive the accident.13 See our selection of aviatioon documents at RareAviation.com Docket No, S-99                                              File No. 98-45CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT....... - =--- APPENDIX I V-G RECORDER The V-G recorder was recovered and after a cursory inspection of the recording glass the complete instrument was shipped to t.he National .Advisory Committee for Aeronautics for study and interpretation. Although it had been subjected to the action .of salt water for a period of about 24 hours immediately after the crash, relatively little of the smoked surface had been washed off the recording glass. Special tests conducted by the NACA revealed that newly applied smoked surface is immediately washed away simply by immersion in water. However, the effect of immersion is appreciably reduced if the smoked surface is old. This recording glass had been smoked prior to December 5, 1944, and therefore the smoked surface was apparently old enough to resist, to a great extent, the action of salt water. Thus it was possible to obtain .from the record some significant information. On the record were three areas of high "Gs"; a .negative area in a velocity range within and up to about .130 m.p.h., a positive area in the range of 100 to 170-m.p.h., and another negative area above 170 m.p.h. Except for a portion of the last mentioned the high "G scratches in all three areas are typical of marks made by a recorder during a crash. -Such marks are usually in the form of irregular scribbling, with the stylus skip- ping while the various loops are being formed. Furthermore, the high speed negative area and the positive area appear to be interrelated inasmuch as the two loops have the same slope and match each other; also the maxirmim absolute "G values are about the same; i.e., 4G. - Greatest significance was attached to a loop within the high speed negative area.- This loop intersected the 4- 1G line at approximately 170 and 200 m.p.h., and the net acceleration at the crest was noted as ---3G. That this loop was not a part of the irregular crash" scratches within the same area-is evident by the following characteristics. First, the loop has a smooth and regular appearance devoid of stylus skip or chatter. Secondly, the higher speed segment of the loop is not in line with, but somewhat separated from, the irregular scribbles previously noted. This regular loop evidently was caused prior to trie breaking up of the airplane. The characteristics of the loop, as expressed by its slope and the negative. "G" value, are not consistent with the supposition that the loop had occurred in free flight.  Therefore, the only -remaining possibility is that the loop was the result of the airplanes contact with water. In order to reconcile the latter supposition with the negative accelera- tion present and with the relatively high          registered,' the NACA con- ducted a series of hydrodynamic tests. These tests were run at Langley  ' ' . 1-1 Field in the impact basin and employed a hull model with bottom lines comparable to those on the M-130. The results indicate that when the hull strikes the water under certain conditions, its bottom is subjected not                                                                                                    nly to local negative pressures (suction) but also to a net negative acceleration,                                                                                                                      The conditions during which this occurred were found to be a -3 trim of the hull keel,                                                                                                                                                                                a relatively high speed, and a flight path  angle, slightly--less than, zero                                                                                                                                                                              . This. seems, to correspond to an airplane in a shallow descent with nose down and at a high speed,' probably with1 some power being applied                                                                                               The tests further revealed that under the above conditions extremely high                                                                                                                    drag deceleration is developed. Although theV-G recorder is not designed to register directly the acceleration (or deceleration) in the drag direction, nevertheless the presence of decel- erating forces acting in the drag direction is apt to affect the recorded velocity "values. With the instrument orientated as it was on the subject aircraft (velocity axis in the fore direction) the inertia of the stylus IP g -M                                                                                       **  ll *  * m rhe presence:W a drag deceleration will result in higher than actual speeds being recorded 'Due to the. complex nature of the problem, and with the testing facilities available at the time, it was not possible to conduct tests which would giveaccurate quantitative results. However, the qualitative results were such as to be-consistent with the negative acceleration within the high velocity range indicated bn the V-G record.- The speeds registered (170-200 m.p.h.) appear to be extremely high, and are not easily reconciled with known facts surrounding this accident. A study of. both the airspeed indicating system and the system supplying the V-G recorder offers no explanation as to why the latter regisr* H tered a speed greatly exceeding that which Captain Goyette last noted on the  airspeed indicator.  There was no'evidence found that water had accumlated in- any portion of the two systems, nor that these systems 'were otherwise net operating within reasonable accuracy. Consequently, it is not possible to establish, even approximately, the speed with which the aircraft hit the water, except to state that it was probably higher than would be expected during a normal landing.                                                         .It .was therefore concluded by NACA that the regular negative loop within the speed range of the V-G record was caused-most probably by theimpact of the aircraft with inter at a relatively high speed. The resultant negative value of acceleration seems in line (at least insofar as direction ?: is concerned) with the results of the-hydrodynamic tests.- , The -high values  of impact speed (170-200 ii.-p.h,) arc net readily explainable-and should be tempered in view of other-known facts. Further, it appears, that the impact took place while thb aircraft ,was descending at a very shallow flight path angle -with the nose slightly depressed from the normal horizontal trim attitude. -1                                                       1                  2 From PilotManiials.com / RareAviation.com See our selection of aviatioon documents at RareAviation.com Docket No. SA-LOj                                             File Mo. 23<35-z;$ CIVIL AERONAUTICS B0 A H D ' ACCIDENT INVESTIGATION REPORT Adopted: March 13, 1946                           Released: Mcxch 13, 1946 PAN AMERICA!! AHV/aXS, LATIN AMERICAN DIVISION, FORT de FRANCE, MARTINIQUE, AUGUST 3, 19h5 *  Flight 216, a Sikorsky S-uJ of Pan American Airways, Latin American Division,* en route from Port of Spain, Trinidad,         to San Juan, *  Puerto Rico, cradled while landing at Fort de France, l&rtinicue at 0                                                                                                            * approximately 1011 EOT 1/on August 3, 19^5. Four passengers were drowned, six passengers and the crew of four survived. The amphibian aircraft sank in about 120 feet of water and was not salvaged. Known as the northbound Island Rim, Flight 216 departed the airport at Port of Spain on August 3, 1%>, at 080\ with Fort de France the first scheduled stop. Preparations for the flight included briefing of the pilot on weather conditions to be expected, forecasts for which indicated squally weather lingering over most of the route in the rear of a receding tropical storm. This store was moving vjest-nortlT<Testv/ard, and at the time its center * was located about 00 miles YJ1T7 of Martinique. 'leather reports showed improvement as far north as Guadeloupe with conditions fluctuating around safe minimums in the Guadeloupe area and above minimums southward to Trinidad. Flight 216 was dispatched on an instrument clearance at an altitude of 10,000 feet with St. Lucia as the alternate for Fort de France. About 100 miles north of Trinidad the pilot changed his cruising alti- tude from 10,000 feet to 8,000 feet to fly between cloud layers. Jithin 9 50 miles of Fort de France turbulent weather was encountered, and the captain 4 y All tines referred to herein are Eastern Uar and based on the 21i-hour clock. again changed his cruising altitude to 6,000 feet, the mininuifi en routealtitude prescribed by the                                                                                    company                           Can tain Shaw stated that at this tiroe  a. ihe'.left.manifold pressure                                                                                                       gauge dropped-about h inches and that adjusti^ijt *                       * w A r                 -A - w - -                       * *                   *  &                                                                                                                  he did not:of carburetor heat did not                                                                              restore the lost pressure. Howeverconsider the situation serious enough to warrant landing at the                                                                                                                                     nearbyalternate of St.. Lucia. Neither the change in cruising altitudes nor theevidence of engine trouble was reported to company flight control. : *              fl                                              .Flight 216 continued at 6,000 feet until radio bearings indicated its \. position to be opposite the Fort de France radio beacon at which point.-itturned to the west, away from the                                                                                                 island, preparatory to making a let-down.About 10 miles west of Martinique                                                                                                 the plane entered an area clear of cloudsand descent was started in a wide                                                                                                 spiral over the open sea. The co^pilbtthen established radio coiamunications with the companys base station andat Q?55 was advised that landing conditions at Fort de France were:. win                                                                                                                                      MlESE 20 knots, visibility                                                                                                          ceiling 2,000 feet, barometer 1012<2ysea moderate vriLth ground                                                                                                                                                     Pan American atFort de France, approved                                                                               bv the Civil Aeronautics Administration. are.:ceiling 1,000 feet, visibility 2                                                                                              : U. lesDuring the let-down to Fort                                                       de France the pilot observed that the.clouds extended upwards from 800                                                                                              feet and that very heavy rain underneaththe overcast made it impossible to determine accurately the condition...of:the water .surface. . Captain Shaw stated that during the .let-down the?left-:engine cut out momentarily and then resumed normal operation with ipdicat-imci the proper manifold pressure                                                                                         Instead of                   encountering the weather -cohditions reported at the pilot                                                                                                       found that                               low ceiling and heavy rainsqualls prevailed with visibility                                                                           reduced to                               about 1/2 mile. Proceeding to Fort de France under the overcast, Captain Shaw circled the company station at an altitude of 500 feet and noted that-the wind-sock indicated a south- west surface wind instead of the previously reported east-southeast wind. Remarking to the co-pilot that he was afraid they would "lose" the left engine and, being apprehensive of single-engine performance of the Sikorsky S-43, the pilot elected to risk a landing under his emergency authority. At this moment the company radio advised that the weather was closing in rapidly and a landing should be lisade as soon as possible. Heading into the southwest wind an approach with full flaps was rrade toward .a .portion of Fort de France harbor seldom used for landing. Captain Shaw stated that during the lattei' part oi'his approach intense rain precluded forward vision through the windshield'and only by opening a side window in the cockpit was he able to see the surface of the water just before the plane landed on the crest of a 4 to 6-foot swell.  On contact with the water and alarmed by the size of the surface swells, the pilot attempted to take off, using full throttles, but he stated that the left engine failed to respond. The    bow submerged and the plane yawed to the right, shearing off the left wing float and permitting that wing to submerge. As the left wing went down - * * .  the aircraft rolled over on its back, rapidly filling with water. Quick action on the part of the crew resulted in the saving of all but four of the ten passengers, several of whom had to be taken from the plane through the submerged hatch. Survivors were picked up by the company- service launch and a private fishing boat* -The crash occurred at about 1011 and the plane sank within 10 minutes*: INVESTIGATION AND DISCUSSION Investigation revealed that a few days prior to this accident the right,a engine of the subject Sikorsky S-h3 failed in flight because of a cracked, rocker box and the pilot had flown the plane for a period of 35 minutes Solely on the left engine. During 15 minutes of this 35-minute emergency,the left engine was operated at a manifold pressure of 38 inches as comparedwith the normal pressure of 26j inches, and cylinder head, temperaturesreached approximately !i50 F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                After prolonged operation of the left enginein excess of rated horsepower, it would have been reasonable to assures thatconsiderable attention would be                                                                                                                                                                  Kiven to the engine before returning the.-.  Wwb                                                                                       * r -r *                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       * aircraft to regularly scheduled                                                                                                                                                                  runs* Howeverf after a routine inspection, a a new cylinder ms installed on                                                                                                                                                                   the right engine and the plane                                                                                                                                                                                              was re turnedto scheduled operations.                                                                                                             The Diane was not                                                                                                                                                                   salvaged at Fort de France                                                                                                                                                                                                           due Ato the deep water in which it sank and no check could be made to determine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           a                                                                                                                                                                                                                                                                                                                                                                                                           I                                                                                                                               . a a a the condition of the engines. Nevertheless, the above incident is signi-ficant as it may account for the pilots unwillingness to pursue                                                                                                                                                                                                                                                                                                                                                                                                     an alternatecourse of action which would have been predicated upon continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              onerati'oh ..of an engine, the reliability of which he                                                                                                                                                                                                                                         was in doubtPan American weather forecasts prior                                                                                                                                                to deoarture of Flight                                                                                                                                                              216 indicatedceilings of 1,000 to 2,000 feet alonp                                                                                                                                                                                                                                                                oute from Trinidad                                                                                                    to                                        Puerto Rico, ; aand the following conditions were forecast for the Guadaioup                                                                                                                                                                                                                                                                                                                                             area:                                                                                               ceiling1,000 feet, visibility 3 miles, heavy showers and winds about 25 knots. *                  aThe Tfeather Bureau also issued a forecast ISLard to Trinidad covering the    a period of the flight which indicated the worst wetithcr to be in the Puerto Rico area and much better weather from about >0 milos south of Puerto Rico: .- to Trinidad. A squall, more severe than anticipated by either of the a a a                       a      _ a casts, developed in the Martinique area as the flight approached and was v                                                                                                                                                                                                     a       v- u - See our selection of aviatioon documents at RareAviation.com closing in on Fort de France at the time Flight 216 approached for landing. Apparently the lowest ceilingand heaviest rain occurred while the landing was being accomplished. In the Caribbean area these squalls arc normally of short duration and improvement can bo expected within an hour# All available information indicates that at the time of departure the weather was marginal throughout the area into which the flight was scheduled. Sone stations along the route wore somewhat below minimums# Flight 216 departed from Port of Spain on an instrument clearance which specified Saint Lucia, approximately 56 miles south of Fort de France, as the alternate airport in accordance with instrument flight clearance requirements. Saint Lucia is served by a radio range, and weather reports for the period of the flight showed that ceilings and visibility at that point were above minimum limits except for a brief period at about 0930 in which the visibility was reduced to one mile. Although Pan American had requested Civil Aeronautics Administrations approval of St. Lucia as an alternate airport for the'Island Run, approval had not been received at the time of the subject flight. Pan American had received authority for instrument flight operation along the Island Route and had established 6,000 feet as the minimum safe instrument altitude as operational policy# However, no instrument approach procedures were in effect at Fort do France and it would have boon necessary for aircraft to remain contact when descending froft'6,000 feet over the radio beacon at that station. Investigation revealed that Pan American had not provided procedures ro guide thoir pilots in transition between instru- ment flight at the safe en route instrument minimum of 6,000 foot and the 1,000-foot ceiling required for landings at-that terminal. ;fhile. it was SeeourselectionofaviatioondocumentsatRareAviation.com * possible to let dcrai in the clear, at least part of the approach to fort, de  --- a France made by Flight 216 was on instruments.   Pan American is not permitted by the French iiovermant to maintain a a  a weather station at Fort de France and is dependent on a French station for.: a a a r                                                                          weather data at that terminal. No special weather reports are available if- % weather goes below authorized minimums . Captain Shaw stated that radio I                                                                                                                                                                                                                                                                                                                                                                                                                         aa * communications and data on weather and landing conditions had never been  satisfactory at Fort de France. Approximately 16 rnnutes before the accidentFlight 216 was advised of landing conditions at Fort do                                                                                                                                                                                                                                                                                           France and, as setA forth above, the conditions reported by radio differed greatly from those.  * actually encountered by the pilot. Furthermore, weather conditions were .such that it should have been obvious to Pan American ground personnel thatthe weather as reported to Flight 216 no longer prevailed and that a safe Xlanding would be difficult if not impossible to effect. The flight was not                                                                                                          w                                                                                                                                                                                                       *  b kept advised in this respect.    * In issuing air carrier operating certificates the Civil Aeronautics. *  Administration requires a radio-equipped launch as a-landing aid to water . ;  *                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                * a terminal ouerations. At Fort de France Pan American had used a chartered <ia            "  i boat without radio oquipront for a period of two or more years. Invcstiga- tion disclosed that this boat was used to carry passengers during the time. * * it should, have boon swooping the take-off path on the water surface.or * standing by for take-off. Pan American had been advised by the Civil. Aeronautics Administration that the boat equipment at this and several other o                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         *            w                  * stations was inadequate. After several months during which no corrective action had been taken, the Civil Aeronautics Administration                                                                                                                                                                                                                                                                                                                                                                                                                   on lay 1,   * again directed the . corrpany  s attention to the fact that the                                                                                                                                                                                                                                                                                                                                                                                                              boat equipment >.-at these bases was still                                                                                                                  unsatisfactory Accidents often occur as the result of a series of interrelated or accumulative.events or conditions. This observation is particularly apropos in reviewing the circumstances related to the subject accident at Fort de France. Laxity on the pert cf the company in effectuating compliance with safe and accepted standard practices in conducting an air carrier operation is reflected in the evidence set forth herein. However, it is logical to assume that if the pilot had known of weather conditions at Fort de France which would be hazardous to landing, and in view of the indicated evidence of engine trouble, he would have remained st the safe cruising altitude of 6,000 feet and returned to the specified alternate at Saint Lucia for a safe landing under favorable weather conditions. FINDINGS Upon the basis of available, evidence the Board finds that: 1.  The company, aircraft and crew were properly certificated for the flight involved.                     ...   2. There was no evidence that any malfunction of the power plant was directly responsible for the accident but abnormal operation of the left engine must be recognized as a factor which influenced the   pilots decision to land under adverse conditions. 3.  Pan American is dependent upon the French meteorological station  < at Fbrt de France for official reports on local vreather, and the - *  *      reports given to Flight 216 were not sufficiently current   *     4. Pan American ground personnel at the Fort de France Station were  * . . not alert to the existing hazardous weather and failed to advise - the flight that a safe landing would be exceedingly difficult. *       - 7 - During his approach to the area the pilot observed the weatheFconditions which actually existed at Fort de France, was aware ofthe fact that they were below the minimums prescribed for thatstation and that the conditions were very doubtful for a safe landing, but elected to land under his emergency authority becauseof stated engine trouble.The company "had not provided adequate or approved let-down pro-cedures between the established minimum en route instrument altitudeand'the' minimum contact landing requirements.PROBABLE C'USEOn                    the basis of the foregoing the Board determines that the probablecause of this accident was the attempt bv the oilot to land the aircraft in JL              V                       1conditions of water 'surface not suitable for landing of a. flying boat-.SUPPLEMENTAL BATAInvestigation and HearingThe Atlanta Office of the Civil Aeronautics Soard received notificationof the accident about 1142 EWT, August 3, 1945, 2nd immediately initiatedan investigation in accordance with the provisions of Section'702 (&) (2) of the Civil Aeronautics Act of 1938, as amended.The Senior Investigator of the Boards Atlanta Office arrived at Fort; deFrance, Martinique, at 0915 on                                                                             August 5? 1945. Considerable effort had beenmade by. the company to recover                                                                                          the plane. Recovery by grappling was Inprac- \  . ticall arid an attempt was made                                                                                          with deep sea -diving equipment brought fromPort of Spain. This was found                                                                              to be inadequate and it was.agreed by thecompany, the Civil Aeronautics                                                                             Board and the Civil Aeronautics Administration that further salvage 'attempts be abandoned.See our selection-of aviatioon documents at RareAviation.com  *  The Board ordered a Public Hearing which was held on August 22 and 23, 19hf>, at the Dade County Court House, Hiami, .Florida. The Chief of the Investigation Division, Safety Bureau of the Board, .presided. Air Carrier . Pan American Airways is a Nqw York Corporation with headquarters in New York and main offices- of its Latin American Division in Ittami. It was operating as an air carrier under a certificate of public convenience and            necessity and an air carrier operating certificate, both issued pursuant to the Civil Aeronautics Act of 1938; as amended. These authorized the flying of passengers, property and nail between the United States, and its territories and foreign countries, including Port of Spain, Trinidad and Fort do France, Martinique. Flight Personnel Captain Sherrill Taft Shaw, age 38, of Miami, Florida, was employed by Pan American, September 23, 19hl, and had accumulated a total flying time of li,298 hours, of which 698 hours were in the Sikorsky S-43. Co-pilot Charles Thomas Hawkins, age 24, of liiami, Florida, was employed by Pan American, September 1, 19h3 and had accumulated a total flying time of 1670 hours, of which 90 hours were in the Sikorsky S-h3. A radio operator and steward comprised the remainder of the crew. Aircraft                             NC lf?O66 was a Sikorsky S---14.3 amphibian, serial number I43O6, manufactured in .{arch 1936. It ms powered by two Pratt and hitney SIEG engines equipped with Hamilton Standard hydromatic, full-feathering propellers. The landing gear had been removed for previous operations, but during June 1945, this aircraft was reconverted to an amphibian and was assigned to the subject run on July 1, 1945*                                                          SeeourselectionofaviatioondocumentsatRareAviation.com a   The airplane' had been operated approximately 12,955 hours ineluding about 220 hours since the last major overhaul. The engines hadapproximately 5,918 hours and 4,495 hours with approximately 327 and511 hours*since overhaul..                                                                                      The propellers had a total time of 5U hours..The                                                        airplane was certificated for a standard weight of 20,000 poundsand at                                                              the time of takeoff weighed 19,996 pounds.                                    The loc-ation of the *center of gravity was within allowable limits.CIVIL AERONAUTICS BOARD:/s/ OSWALD RYANs/ HARLLEE BRANCH- /s/ JOSH LEE10 -From PilotManuals.com /-RareAviation.com Docket to. c.A-113                                                                                            File ho. 851-46CIVIb AERO I. AUTICo BOARDACCIDENT INVESTIGATION REPORTAdoptea; iTove^r 1, 1916                                                                         Releaoea/^ov^mjpj 6.1916.Phi. AMERICA aIPRaZo - VIbbliANTIG, CONNECTICUT, June 8, 1^6T*.e Accioent *                v         --- t A Pan American Airrayb Lockheed Constellation, designated ao Trip 100, * en route from hew York, L. Y., to London, England., *ao landed at vinahan Air- port, kiixiMintic, Connecticut, at 1700 , June IS, 946, with wheels retractea, following a fire in Itfo. 4 engine ana subsequent iost> of the engine during flight, ho injuries vere sustained by any of the occupants as a result of either the 9 fire in flight or the emergency landing. History of the Flight Pan American AirwaysTrip 100 departed La Guardia Fifeld, beu York at 1601, p June 18, 1946, en route to London, Sngiajjd, with stops scheduled at Gander, Newfoundland, and shannon, Ireland. Under an instrument Air Traffic Control clearance, the flight climbed on course to an altitude of 15,000 feet and re- ported reaching that altitude at 1633. The flight reported over Hartford, Connecticut, at 1637, and until that tine nad been completely routine. At 1651, the fire warning bell sounded and the light for No* 4 engine c9Kzne on indicating a fire in that nacelle. Tne emergency engine fire pro- cedure m.ediately initiated in the following sequence: The throttle fully retarded, the mixture control moved to idle cut-off, the propeller feathered and the emergency fuel and oil sroit-*off valve moved to the 11 off" ^Ali times referred to in thia report are Eastern Standard and based on the 24-hour clock. position, immediately thereafter, the engine fire extinguisher control movod to the No* 4 engine position, and the first bottle of CO^ TOS emptied "'into the nacelle in an attempt to extinguish the fire. Although the flameswere mp.ntari 1 y retarded, they soon burst out a gain, and a second bottle ofCO^ was e mptied into the nacelle with similar results. The auxiliary COp bottle was used as a final resort but, as with the previous attempts, thefire was nob permanently extinguishedHaving already passed Hartford, Connecticut, the captain was aware thatweather conditions m its vicinity were satisfactory for an emergency landingInasmuch as the flight was, at the time of the fire, above a thin stratus ovencast, and since the captain was not aware of the weather conditions at nearby - 3 fields, he decided to return to Hartford rather than attempt to locate airport 3which nay have been slightly closer but the vreathor at v/hich may have causeda greater delay. In order to return to Hartford as rapidly as possible, thecaptain descended with power and at a very high indicated airspeed which ulti^tmately reached 300 mph. Because the aircraft was continuing to accelerate,the captain partially extended the flaps and reduced the airspeed to approxi---mately 25 0 raphDuring the nign speed descent, the flignt crew observed the propeller on. Ho. 4 engine turn slowly despite the fact that it was fully feathered. Flaheswere pouring from the top inboard louvers of that engine nacelle and were in-creasing in intensity during the descent. At an altitude of approximately7,000 feet, about four minutes after the fire warning btrEL scL86fte,"the-No. 4 -w engine suddenly swung dowrsnrd and fall free from the wing. Fluids continuedto pour from the broken lines sir earn mg behind the nacelle with an appearancewhich semewnat resembled smoke. Some flames were observed in the wing near i the leading edge on the inboard side of the No. 4 engine position after the .ag- ' <||g engind fell from the aircraft. Shortly thereafter, the aircraft entered j^Cvercast and continued- through th6 stratus cioi^p' eh roudie to Hartford, nt approximately 3,000' feet, the aircraft broke out beneath the* overfeist ' '          *"        *'*'* V* - and at that tune no fire witnin the wingwas -visible to any of the crew members The captain, sighted Windham Airport at Willimantic, Connecticut, and being certain of the damage incurred as a result of the fire, he decided to Und^t/ *        *f that field rather tnan prolong the flight to Hartford. In attempting to lower 7 the binding gear, it ms observed that the hydraulic system was inoperative a result of breakage of hydraulic lines m the No. 4 engine nacelle. Rather * J than lose any more time than necessary, the captain decided against attempting to actuate- the emergency guar extension system and landed as soon as ho was.:' able to establish an upwind approach. The landing was accomplished to the - northeast with partial flaps since no additional flaps could be extended sub-  sequent to the losg of jjo. 4 engine.The landing on the belly of the fuselage was very expertly accomplished, and little damage to the aircraft structure ,s sustained as a result. ?tone of the occupants was injured as a result, cither of the fire in Flight, or the -emergency landing.Immediately after the aircraft came to rest n W^ham : * -Airport, all occup^rtte declared safely. , Invcsti at ion  ' *The aircraft lay on thcrturf a short distance from the Northeast runway,  facing the northeast, ^ith the exception of the damage resulting from the *   * fire in the No. -4 engine nacelle, bunt propellers on the three remining engines and minor winkles on Ro, 2 and No. 3 engine nacelles, little damage to the \ ? aircraft ivas.-observed. - The No. 4 engine and most of the nacelle wore rd ^^2. - 7 from the right wing. Evidence ms observed -of .fire of considerable intensity within this nacelle. Fire had-extended to the front spar of the right V- the^Joadihg edge as far inboard as the No. 3 engine nacelle. The :-3-i oad aurned through                                                                             a ne-.ly installed baffle, the function of nick had                                                                                                                           2^2^? - - .Ato prevent a draft                                                                             through this section of the leading edge. T^e                                                                                                                  heat      hade: ? been of sufficient                                                                             intensity to suckle                                                               approximately five feet of                                                    the upper 5oortion                               of the leading edge inboard of                                                                                       the So, 4 engine nacelle,Investigation of the fire pattern                                                                                                          disclosed the greatest concentrationof fire to have existed along the top inboard area of tne Jo. 4 engine nacelle Analysis of the nacelle failure indicates that this section of the nacellestructure became weakened by fire and failed. The engine and cowling hadswung now tearing away the remaining portion of the nacelle and falling free  froi? the                                                     ,;rLriS* itn the separation of the engine Iran the /mg structure,-fire had                                                                                                                                                                                                                                                                         2 apparently continued in the remaining part of the nacelle for'a short -Av period.                                        The steel shroud vhich had been installed to shield rhe front sparhad been                                                      foldea over exposing, the inboard region to fire The reb m theboard section buckled and subsequently developed a prominPnt, exposing the interior of the                                                                                                     integral fuel tank, Ho-ever, it isapparent that the crack had been produced                                                                                                                                                                                           after the fire in that region was- -xhsctingiished. Examination disclosed that                                                                                                                                                                                           the fuel level^-nthm the tank has <*-                    V- considerably holo the crack in the v/eb.:  T'5e i<Q* 4 e^ine ^as located on a farm on wnich it had fallen, at - approximately 14 miles east of ' uidharn Airport < It is apparent that several Xz sections of the nacelle had fallen^witially, K4                                                                                                                                                                                                                                                            ed in sequence by the main electric junction bex, the'alcohol tank the cabin supercharger and driw snaft assembly- and                                                                                                                                                                                                                                           MB the engine proper, These                                                                                                        copponents vere located over an fl                                * sack along the                                                                                                                                                                 ilight path covering approximately miles ftoa the poM * - *, came                                 to rest.                All engine and accessory canponents andg sections                                                                                                                                                                                                                                                                                 7 vrere                                                                                                              thoroughly for indication of fire and/^r'The major portion. of all fluid-carrying Jural lines, bulkhead fittings and flrerall attachments in Zone 2 rexe consumed by fire, as ere alnost all -x- dural lines aft of the fireral) in Zone 3. The emergency oil shut-off valve -as founc rear de engine in die closed position. nene of the several enginecomponents examinee revealed any sign of malfunctioning althoagn several bore signs of intense heat, kn examination of -ohe porer section vas accomplished but no indication of mechanical failure - as disclosed*A detailed examination of cabin supercharger drive shaft assemblydisclosed a signiJicar.t ca function of failures, Both tne inner aiyi outerrace of l ic ior-rard 'earing of tie dri^e s^aft "ere mutilated in a mannerindicating failure due to inadequate lubrication Grooves oat into the uni-versal joint unclosed that sone of we balls fro the shaft rearing had fallen into the joint subsenuent to failure of the bearing resulting in extensive mutilation of the universal Joint legs. The drx^e coupling, ,rbich is the direct connection .et eon th drive shaft and the engine accessory gear sec--- tion, "as locates intact* This i*nit is designed so as to permit a failure insnear Hirer unusually nigh torsional load conditions.                                                    No indication of exces-sive- shear forces 'ore observed in tnis unit.Lx a- motion                    of that part of the hydraulic system           mthin the nacelle re---vealed no malfuncticn of the hydraulic pump, he xver, the high-pressure hese fittm attached to tne pump showed definite signs of abrasions on tne under-side inch had undoubtedly occurred orior to                                      mpact "ith the ground* This------------------------- p y fs to ?o' SGCti<> or th?t rrc-d of the engine naeslle forward of tec di?phragn. Zone 3 is tao accessor-- Action or that area of the engine Sr^tte                  and fchc               3 is the nacelle area jtA-fMy ;XzFigure 1.                                 An  enlarged     view          of the                    disassembly        of the      engine and                                                                                                 end of the cabin supercharger drive shaft B.  the hydraulic out-11             C uLrsa?VidiTine tha U&tUre OI' the                  "bearing Universal joint, shear section; F. Hydraulic out-fit^L r > AluDlinumf ^Ing-shield; E. Dnive coupling posing stsel braid),                tin8> * Hydrauilc (rubber covering consumed ex- From PilotManuals.com / RareAviation.com fitting is located approximately 3/8 above the forward end of the crbin super- charger enve shaft. The cabin supercharger drive shaft universal joint hous- ing, which is attached to the engine gear box, had fractured circumferentially at the ir.ia-scction, ana the rear half' of the housing had mo ed rearward and was loagcd over the spring assembly expardur. Its ragged edge bore indications of having struck adjacent objects ana was rolled inward in such a manner as to inGicate considerable force of contact vrhile rotating. The shut-off valves for the fuel ano oil systems are located at the fire- wall in Zone 3. fire confined to Zone 1 or 2 ana of sufficient intensity ** to consume gasoline or oil lines in those zones woulo not be fed additional fuel other than that contained in thu lines if the shut-off valves were ac- tuated. However, such protection is not afforded Zone 3. Moreover, both the fuel ana oil shut-off valves xnry be actuated only after the propeller is fcatnvied which leaves all such linep forward of the firewall fillea with inflaijnaoK fluxos of sufficient quantity to aggravate the fire severely in the event tney wen consumed sufficiently to permit leakage. Inspection of the firewall disclosed tre fact that all dural flanges anu host, fittings attached to the firewall and eirectly vithin the flame OB           prth werv consumed by fire, ft therefore became apparent that while the firewall itself may have provided relatively good protection for Zone 3   - " . from any fire itfnch originated in Zone 2, when the dural fittings '..ere burned or melted out, the effectiveness of the firewall vias seriously 1 united 3BU Cirfa. IIS able to penetrate into Zone J Ft several points. ki air filter unit haa been included originally in this aircraft and had been installed on the aft side of tU farewall -.a thin an integral fire- wall air ouct the dimensions of which were approximately 8 by 10. The duct ext e-ndou almost-vertically to 1-3/1; from tne xop of th. nacelle. Prior BSrtfco the accident < the filter had been removed from the system exposing the duct rAWM'sto Zone 2. The opening left when the filter unit was removed had not been > -^b - covered. Tms was contrary to the manufacturers instructions * Consequently, 1 - the firewall was not capable of completely preventing nenutratien of possiblefire from Zone 2 into Zone 3.In the absence of a steel plate covering for the duct, the fire whichbroke out in Zone 2 pas                                                                                                                                          sed with little difficulty                                                            into Zone 3 and,                                  becauseof the                                                                                                            lack of fire extinguishing                                                         equipment in this                                           area; the fuel carrying1 i nes were quickly consumed and the fire developed to uncontroliible proper--- tions.This model aircraft was equipped with fire detectors in Zones 1, 2 and3, as well as m the induction system.                                                                                                                                                                         Two separate fire detection circuitswere installed in each nacelle and                                                                                                                                                                      each circuit ms                                          provided         with a separateWarning light in the cockpit. One of these circuits included the engine induction system and the other circuit included the three nacelle zonesthis instance,                                                                                                                                 the flight crew observed                                         that the warning light                                                    idiich indicatesa fire in one of the three                                                                                                                                                  zones m No                          4 nacelle came on. Inasmuch as theinduction system light did                                                                                                                                                  not crane on,                       the flight crew assumed that no firehad occurred in this area                                                                                                                                                   The fire extinguishing system is so installedthat approximately 70 percent of the 00^                                                                                                                                                                                      is directed to Zone 1, 23 percentto                               Zone 2 and 7t percent to the induction system. No agent is supplied Zone 3. Should an engine nacelle fireto                                                                                                                                                                                                      penetrate to or originate in ^oneno means of extingiilshineni- are-available to the flight crew< Furthermore,the entire system as designed                                                                                                                                                           in such a manner that, regardless of the locati-on of the fire, the                                                                                                                                         distribution of the extinguishing agent is apportioned r* subject accident, although three a the                                                                                                same ratio                             In    the                                                                                                                                     e bottles -fc*                                            '-s              %-> of co2 haa bcui discharge! i-iw thv- nacelle, none of the ?>>nt proved effec- tive in extmoishinr; the fire in Zone 2 or 3. Lis cuss ion ^Itho^rh the flight erew fo l^vca the yrocecur^g Tor counting povor plant fiics in a satisfactory' manner and utilized tn^ fire extinguishing c^uipiauit as complvtul* as possiolej there is no aoubt trat the fact that Mo. 4 engine fell from thu aircraft at tru moment it cio proved to be the most effective single lector in removing tri danger to the ving structure, z immediately prior *o tearin loose from tne un;, tnu xiacelle con^aiaca * every evidence that t^e fire was increasing in intensity; that there v.as no aopv of thv firU'burning itself out; anc. that no further corrective action on thu p^re of tl v cruz -vzs practicable, Hne rhe engine nacelle remained intact lor a longer period of tim~, it is curtain that the fire would have uakuned thu * mg structure sufficiently to cause failure of a mJ or wmg component or' combination of components. There is, furthermore,  reason to oelieve that the fire urnld have spr^ao into thc ?o. 3 engine nacelle had not the major so-rce of the fiTu been eliminatea uhui the engine tore loose. The damage to tae spar moicates forcibly tne narrow margin under sfticn the aircraft 'as operating at the moment thw engine was cropped and very little adaitional h-at eoula have been reuiir^d to ignite the fuel V i/xthin the integral tanks. The fact that almost all tne flu id-car raring aural lines in Zones 2 and 3 were partially conauaLc: by fire inaicat-s the necessity for materials of greater h^at-resistant qualities in chose lines carrying inflammable  fluids. Regardless of  huter shutoff valves are incorporated m the re- spective systuns, the a^^regate capacity of all gasolirt, oil, alcohcl, -a- .&                                                                                                                          5kand hydraulic fluid lines furnishes a source of fuel for nacelle fires whichmay develop a fire of severe proportions. In the event the feathering actionis not complete and the propeller windmills while the fire extinguishing pro-cedures are being executed, the contents of tne oil sump may continue to draininto the area of fire if the lines m this region are consumed. Tne lines aftof the firewall presented an even greater hazard in this respect inasmuch as ?the action of the shut-off valves did not prevent the continued flow of in-flammable fluids through fractured or fire-consumed lines.It is apparent that the contents of the fluid-carrying lines contributedto some extent to the fire in tms instance. Because the shut-off valves can---not be actuated prior to completion of the feathering action, the lines retainfull capacity of their resoective fluids. It does not appear impracticable toso design the system that these lines be emptied of their contents prior tofeathering but after the ignition switches have been shut off. While thefire-resistance of empty lines may be less than those lines which carrv fluids,they nevertheless present                                 less of a hazard in engine nacelle firesThe effectiveness of                                  the firewall appears to he of paramount importancein consideration offices                                  as occurred in this instance and the evidence la-dicates conclusively that                                 the effectiveness of the firewall was seriouslyimpaired as a result of the burned and melted flanges attached to the firewall. Fire penetration into Zone 3 was possible through the large openingsleft in the firewall when these dural flanges were burned out. It appearsurreasenable to incorporate in the firewall fittings and attachments of suchcomposition as will substantially reduce its effectiveness particularly mview of the fact that materials are available which will jrovide a fireresistance almost equivalent to that                                  of the firewall itself. The omissionk.*   , v                  * * -X>- r                                      < of the steel plate over the opening left vhen the air filter had oeen removed from the firewall was clearly an oversight*and the rapidity with which the fire increased to severe proportions can primarily be attributed to this factor. / .Unless an engine nacelle fire can be effectively isolated, extinguishment tech- niques 're rendered extremely difficult.Evidence of severe heat on the baffle between engines Ho. 3 and No. 1;, on the wmg structure adjacent to the nacelle, including the front spar andon the steel shroud protecting that portion of the spar circctly behind Ho. u engine, indicates clearly the need for additional protection of the aircraft structure from engine nacelle fire-s. The greatest single danger from such . - fires lies in the potential damage to the wing structure, and it wrs apparent that the fire was in no sense confined to the nacelle in this instance. Al- though the steel shroua mentioned above proved a valuable shield for the front spar, similar protection should be provided the remainder of the critical wing structure lying in the probable flame path of a nacelle fire. Examination of the cabin super charger drive shaft universal joint hous- mg ana the adjacent hydraulic fluid line one fitting reveals the probable 7 J origin of the fire. The forward bearing of the drive shaft failed as a result ol lock or ta ncatlcn. Failure of this bearing ceased the universal 3olo6 io vhxp violently end bv.-.t against the inuur surges ci the universal Joint housing. The housing eventually fractured CircWcruntidly cud the roar por- tion bCT rr t0 rotate Tath sWt                      ? of the violent .tapping aotlon ,*toh touted*5^ e66Uq Tho iircBcll shell conplctclv isol-te the                 . rnd shall have all n^cessar openinge              i -ngine comoortment -b^iligs. (Part <4. M                  :1wSTC'tXtt11* sr~te or W >9^14jl                                                                                                                                                     4y>* >tf /Jin <1 -<:'*W* B4'7^>; BaHi * fe  = Wi MS Zn T- t s: VFigure 2.                                  The cabin                      supercharger drive                      shaft assembly installed in IIC 888.58 is shown beside                  a new unit. The drive                      coupling shear section (E) is shown partially installed.The shaft                      bearing failed due to lack of lubrication and the inner race (A) becane                                            eparated from the outer race. ThJs resulted in violent contact between the universal joint (B) andthe universal Joint housing (c). The housing eventually fractured circumferentially and the shaft was permitted to vibrate while rotating. The fractured edge of the universal joint housing (C) stall on the shaft contacted the hydraulic out---fitting (F) breaking the seal and causing a spray of hydraulic fluid throughout the area.The drive coupling shear section (E) was so constructed as to permit a failure m shear un- der such circumstances. This unit, however, did not shear in this instance and the failure occurred in the universal joint housing instead.Item 1                indicates the aluminum spring-shieldItem G indicates the hydraulic line with the rubber covering consumed exposing the steel braid.From PilotManuals.com / RareAviation.com supercharger unvc shaft and housing came in contact with the hydraulic line fitting; t ith considerable .force causing leakage of hydraulic fluid. Inasmuch as this line is under a pressure of at least 1,500 pounds per square inch, the fluid evidently released forcefully in a fine spray. The cause of the ignition of the hydraulic fluid was not positively eetennined, however, block tests ; ere conducted on the supercharger drive shaft b, Lockheed Aircraft Cor- poration in vhich such a situation was simulates, ,anu it was dcturminca that this condition resulted in a shower of sparks accompanied by considerable heat. These t^sts revealed, furthernoru, that the heat developed in burning out the supercharger drive shaft bearing and fracturing the guard left the universal joint red-hot. The f^ilur^ of the universal bearing, therefore, was capable of causing leakage of the hydraulic fluid ana of producing the heat necessary to ignite it. Shearing of th unve shaft coupling wuld have prevented the damage which resulted from failure of the forward bearing by permitting the drive shaft to stop. It is not known vh ether the torsional loads for "hich thv unit reas de- signed exceeded those encountered in this instance. However, failure of the shear section hr a rvertvd serious damage in other occasions in which the super* chrrgcr drive sir ft bearing had failed in this model aircraft. Because of the difficulty of designing a shear unit adequate for all possible load conditions resulting from failures in the drive shaft assembly, consideration should be given the installation of a more satisfactory means whereby the shaft may be disconnected from the engine accessory gear section* Because of the extremely high pressures at wiich hydraulic fluid is con- ducted through engine- nacelles and the relatively high inflamaebillty of cur- rently used petroleum base fluids, hydraulic lines present f particularly significant hazard. The evidence obtained from the investigation of this <:r---.^ i?     S > Y.- :2X--^r -.-s-jFigure 3.                       Build-up o: the pc>Atr il-rz                                                   , h - <               4* ---...1. c Cx L- of the car:n sjuerchar-e 5                                Cl*"                                           < f u *< -*               A- WFw           -A- V nf;-2 i_< hydraulic out-fitting. From PilotManuals.com / RareAviation.comaccident irdicav.es that a lockage in a n^draulic line or fitting often re- sults m a fine spray of hydraulic fluid can* forced into the racelie under extremely nighpress ires. The explosive manner m ihich such a spray of hydraulic flaic. ignites has been effectively remonstrated m Lockheed lacorotory -ests eonauctec3 since tris accident. It is "hereto-e urgent that fluios of l<,sjcr conoistisi3ity be developed for use m nocem aircraft as soon as possible. At least two such predicts have coon oo-elcped to date but urc prirv.ry obstacle to the immedi'ue use of such fluids is 'he l-ck of ser-'ice o Su o >ta as ro their usability ''iuh_r nydraulic systems incor- porated in ircraft errly in service, ( It is significant *nau unaer the conations Gr 'his acci.ort the evi- dence discloses little '5-parcT. effu^1 V-e COo or. fire, nltnough the * * flames ver? retjrded orx.aril^ lolZ-o^ir." iX         oisch^r^e of CO2, they irnjr.ediatelv ^roke out - exn rxun even greater i^tensiTV, The following t^o discharges evicentl-' h?o no effect. It is <i^ficel+ to determine accurately v;he'"cr the risc^rge pas inadeouate to extinguish the fire at all, or whether * tic substance ^ich ^as burning ras beir.g released un er such circurstances .nat| it. tec-amc ujived1 :tcl t reignited. Fov?ever, it as demonstrated m sub- secuent. Tests that 'hile universal joint T?as curnec sufficient heat vias developed to continue tl e combustion cf the hydraulic fluid as readily as oxygen oceans <svail'>ble. I' is im-ortent nevertheless io consider that the lightness of vhe COg would facilitate dissipation in t-<v air'lo i rhrouTh'the nacelle, anH ^h=t the effectiveness of C02 is veil knewn to inferior to vhet of methyl bromide and wnocnlorferoiwicthane as a fire-exwngiiishing agent. In n^i? oi the f->ct the at apuabiiity of uhese agvnts uo air caiier air- craft has nor been ae.eriiaod coE-^lctelv, t}<,re is undoubtedly r nczd for mare intensive research into ihc applicability oi superior                                                                                                                 agents to aircraft fireextinguishing systemsIt IS belleVud,                                                                                      furthermore, that tho absence of                      discharge nozzles intoZone 3 deprived tn t                                                                                            region of the fire protection it                      needed in this instanceIt appears illogical                                                                                            that a detection advice should be incorporated in thatzone to uarn the pilot of the existence of a fire ilicn no mtms arc availableto him of extinguishing such a fire. All research data available prior tothe time of the accident,                                                                                                however, indicated that the distribution of the fireextinguishing nozzles incorporated                                                                                                           in this power plant was              ccomplished in accordancu uitn the bust information                                                                                                           available to the aviation industry.                       Theadvent of ?owcr plants of rhe size                                                                                                           and operating in the temperature range ofthe type engines involved poses problems uhich require a recvaluation oi thesafety techniques developed on the basis of earlier pov'er plants. Foremostamong these?                                                                                 Certaiiili- de those techniques ocsigned to prevent or controlengine nacelle fires.FindingsUpon the basis of all                                                                                              available evidence the Board linos that:1* The Company, aircraft and crew v.eiu properly certificated for theflight.Thft portion of the flight to a point                                               abreast Providence, RhodeIsland,                                                       nad oeen entirely routine with nothing                                                    unusual having been observedAfter the aircraft had been in flight                                                    pproxinhtuly 10 minutes, thesuperchnrge-r drive shaft bearing failed due to                                                                                                         inaoequ'te lubrication^ theUniversal joint housing attached to the engine                                                                                                          gear box fractured in its mid-section and struck the hose-fitting on the outlet line from the hydraulic pumpsufic-iontly to cause a leakage of nyoraulic fluid into Zone 2.<*                           z1 From PilotManual$acom / RareAviation.com 4* Failure of the forvard ball bearing of the supercharger drive shaft, and subsequent ^allure of the universal joint housing generated sufficient'neat to ignite the hydraulic fluid. 5.  The drive shaft shear coupling failed to shear in this instance and no means were available to aisconnect the supercharger drive shaft from r the engine accessory gear section. 6.  The engine fire warning bell sounded and the fire warning light cane on indicating fire in one of the three zones of the No. 4 enginenacelle. No fire ras indicated m the induction system.1 7. The flight crevr observed flames coming from the too inboard louversif the No. 4 engine nacelle.8,. Normal emergency fire procedures were executed by the crew and all,hree bottles of CO2 were discharged into the engine nacelle. ,$ The first discharge of COj retarded the fire momentarily but thetub sequent two discharges had no apparent effect upon the fire.10. The fire consumed almost all fluid carrying lines in                    Zone 2 andncreased rapidly in intensity.11. After penetrating the firewall through the uncovered                    air filter ducthe fire partially consumed most of the fluid carrying lines                                   m Zone 3 12. No fire extinguishing discharge nozzles were located                    m Zone 3Ithough one fire detection unit had been installed in that area.13* Having burned for approximately four minutes, the fire weakened the sufficiently to cause it to tear loose from the wing aW acella structureall*free.14. Some                   fire            persisted in the -wing for a short while after the enfiwace lie fell                                from            th? aircraft. <    1>. ,7hile. the fire was in progress, tho captain descended at high speed, returning towards Hartford, Connecticut, with intentions of landing at theairport located near that city                                                                                                                                                                                                            * ->16 The aircraft entered a thin Stratus overcast at appiralwiely 4,000 fevt ana broke out beneath the clouds at 3,000 feet.17. After breaking out beneath the overcast, no fire was visible to any * of                                                              the crev' members.18. Upon sighting Uindham Airport, Willimantic, Connecticut, after estab- lishing visual contact, the captain elected to land at that fiel19.          Inasmuch as the hydraulic system was inoperative yr with the                                                                                  landing gear                        retracted and with the flaps partially extended.No injury to                        any of the occupants was sustained as a result of                                              eitherthe fire                                                                                  in flight or                        the emergency landingProbable                                                                                  CauseThe Board determines that the probable cause of this accident ws fire V in the No. h engine nacelle due to fracture of the universal. joint housing of the supercharger drive shaft, 1 ana. subsequent ignition                                                                                                                                                                                                               5          -ft                                                               9ConclusionAs a result of the                                   investigation of this accident the Boardthat:* H          ajor wing                                     structure m the vicinity of the engine nacelle ^aanot te3mtoly promoted fron possible enetao nocolle fir. 01 aircraft. 2. hural and other* allots oi aluminum arc not sufiXcioutly rdistant -to heat to warrant their use in                                                                                                                                         S* lines conducting mfl.anmnblo fluids within the4                                      *> Having been located at                                                                    the firemil, the shut-off valves afforded ft*                <                                   V*- 4-'~                                                                                                                                        V z -4' x-         :/  no protection from possible drainage of highly inflammable fluids through frac---' tured or fire-consumed lines in Zone 3. 4, Because tne shut-off valve mechanism cannot, be actuated until after tne propeller is feathered, the fuel and oil lines throughout the engine nacelle retain their respective fluids after feathering has been accomplished. The presence of such fluids within the nacelle presents a definite fire hazard. '5. The effectiveness Of the firewall was seriously, limited by inadequate sealing and oy the use of dural fittings. 6,  The design and location of the cabin supercharger drive snaft installed in tne 049 until the time of this accident presented a distinct fire hazard because of its susceptibility to poor lubrication and its proximity to the hydraulic lines, 7,  Petroleum base products presently in use as hydraulic fluids are excessively inflammable particularly in view of tne fact that materials of lesser combustibility have already been developed. Service test has not been accomplished on any of such fluids. 3 Tne carbon dioxide fire extinguishing system was not adequate to extinguish tne fire in Zone 2 sufficiently to permit the flight crew to re- * rjove the fuel source and the cause of ignition.9# The distribution of the fire exiinguidung -Dgont througnout the nacelle was inadequate fox- some fires. Mo extinguishing agent vzas provided in Zone 3.BI THE CIVIL AEROIiAUTICS BOARD/s/ J. ]A. Landis /s/ Qst raid Ryan /s/ Harllee Branch * / s/ Josh Lee /s/ Clarence M. Young        - - - 16 -                               '        , ,          < t         S                          *    *        "**         ,.       a.* t f             **           ** AppendixIntensive research was accomplished by the Safety Sireau                                                                                                                                                                                                                           into this andother recent accidents involving fire in .air carrier aircraft                                                                                                                                                                                                                                                                       in order thatthe most effective action possible may be taken,. Coordination was accomplishedwith all agencies concerned in the preparation                                                                                                                                                                                                                                                   of an amendment to                                  those partsof the Civil Air Regulations pertaining to air                                                                                                                                                                                                                                                   transport aircraft                                       and opera-tions. In view of the vulnerability of Zone 3                                                                                                                                                                                                                                                    te possible engine                                  nacellefires and the potential danger which exists m                                                                                                                                                                                                                                                    damage incurred by                                  the criticalwing structure in the vicinity of the engine nacelles, the Civil Aeronautics                              V Board promulgated additional regulations designed to isolate more completelyZones 1 and 2 by increasing the effectiveness of the firewall in aircraft inthe air transport category, to improve the systems of fire detection and ex-tinguishment in both the                                                                                                                                                                                                                           fuselage and engine nacelles, and to increase thefire resistant qualities                                                                                                                                                                                                                           of engine      nacelle components and aircraft structureThese regulations become                                                                                                                                                                                                                      effective           November 1, 1946The                                   manufacturer had foreseen                                                                                                                                                 some of the implications of engine nacellefires in                                                                                       the Model 049 aircraft. For instance, the stesl shroud protecting                                                                                                                                                                                                                             %                                                                                                                                                                                                                                      /1-the main                                                                                                                                                                                                                                                                                                                                -V spar directly behind the nacelle and the Zone S engine fire detecticf                                                                                                                                                                                                                    I'dunit had                                                                                       been added                                                                                                                               1 though no such protection had been provided other aircraftmodels currently in                                                                                                                                                                                                                 air carrier service nor were any requirements in existencewhich rendered such                                                                                                                                                                                                                                                                           installations mandatory. This accident discloses, however,that the fire protection in the 049 engine nacelle ^as not totally adequate andt that further attention "was required to correct deficiencies m fir a -rrewntiTO equipment* The remedies being effected as a result cf this investigation ^11?not be confined to this particular modelAircraft but will be                        extended vdiertvernecessary to include                                                                                                                                                                                                                    all          air erh ft      in           air       carrier service*-k                                                                                                                                       * X X s                                                 *                                                                                                                                                                                                                                                                                                                                             { / i -j -nQ- .x-.i          ' *_>'VT -S      g,               J                                                                                                                                                                              From PilotManttaT&&om XRareAt^tionTC&nr ' - cX- SUPPLEJfENTAL DATA                              ,    . % Investigation ** --- The Civil Aeronautics Board was notified of the accident at 1745, June  * 18, 1946, ard an investigation was imniediately initiated in accordance with * tiie provisions of Section 702 (a) (2) of the Civil Aeronautics Act of 1938, as amended. Air Safety Investigators of the Board's Now Tone Office arrived at the scene of the accident at 1130 tnc following day, and were la tor as- sisted in the investigation by other menoers of the Safety Bureau Staff. A public hearing "was ordered by the Board and was held a t New York, E. Y., June 28^ 1946a Air carrier pan American Airwajs, incorporated uider the laws of Delaware, ana having established its heacquarters at New York, N. I., was operated under a Certifi- cate of Public Convenience and Necessity and an Air Carrier Operating Certificate, both issued pursuant to the provisions of the Civil aeronautics Act of 1938, as amended. These certificates authorized ?an American airways to transport persons, property ana nail between Nev; York, USA, and London, England, Flight PersonnelCaptain Saruel H. Liiller, ago 29, of Tfliite Plains, New York, was pilot of tne aircraft. Until tnc. date of the accident, he hac accumulated a totalof 6,000 hours flying, tine, of which 226 hours were obtained in Lcokbeed 049 aircraft# First Officer Joodrow L* Ladson, age 28, of Beechhurst, JJ. Y*> vtas co-pilot. He had accumulated a total of 1,802 hours flying time until the aate of the accident, of Ciicn 20 hours were obtained in Lockheed 049 aircraft. John J. Howell, Second Officer, Perry T\ M^amord, Third Officer, Charles Kaufman, Engineer Officer, Gerald 5yj Assistant - Engineer Officer, Bal ph S. Gibson,                                                                                                Radio Officer, Frederick GusmanAssistant Radio Officer, John F. De Rudder, Purser, and Beatrice Avenia,Stewardess, comprised the rema mu er of the crew. All flight crewpeisonnel were properly certificated or otherwise Qualified for theirospectivc. duties.ra ft I I 1TC 88858, a Lockheed 049, Coatellation., was manufactured in                                                             Apr il,1946, and had until                                                                                         the date of the accident accumulated a total           of 387hours flying time                                                                                           Four 'right Duplex 739 C-18BA-2 engines '-ore      installed,each rated at 2,200                                                                                         horsepower. The engines were equipped nth HamiltonS-baudard propellers. Each engine hao accumulated a total of 387 hours/ > since installation during manufe chirp. At the time of tako-offfro-. LaGuardia Field, the total weight of the aircraft was within itsjininvn gposs loaa limits, and tne load was distributed with recits                                center                                  of gravity within apnrcved limits-3 -                                   4      1? 4>; _ :<1 Oocket No. SA-139                                                                                Ffie No. 6985-46CIVIL AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: October 20. 1947                                                  Released: October 21, 1947PAN AMERICAN AIRWAYS, INC.---NEW ORLEANS, LOU ISI ANA---DECEMBER 19, 19U6The Accident                                                            Captain Sidney A. Adger, the pilot, Pan .American Airways Flight 702. NC-                                  called Moisant Tower after crossing the88897, a Douglas DC-4, collided with                                    Barataria marker, reporting that he had trees in 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.1 The tower then cleared the Brooklet Field. Mobile, Alabama, landing                                flight to land on Runway 30 at the cap- safely at 0105. December 20. 1946.                                      tains discretion, and stated that the altimeter setting was 29.93 inches. History of the FIight                                                   Flight 702 reported over the New Or- Flight 702 originated at Balboa, Ca-                                    leans range station at 2357, made a standard instrument let-down" on the nal Zone, December 19. 1946* 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 Adger's 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 V2 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                                 heavy ram. Captain Adger climbed to an the Moisant Tower, and instructed it to                                 altitude of 500 feet, and held a heading cross the Barataria fan marker, which is                                of 100 degrees for a period of one min- approximately 20 miles south of the New                                 ute. From that time on until the land- Orleans range station, at 1,500 feet or                                 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 Al) times r^fer^ei to herein are Central Scaniard                       approach, the tower transmitted the fol- Time ano base'' on the 24-hour clock                                    lowing 2228 weather observation. 2                                                                                                              Accident Investigation Report"Indefinite 200 overcast, lower scat-                                                     and vibration. Clearance to Mobile at tered, visibility 2, heavy ram, light                                                     an altitude of 2,000 feet or belowfog, 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 lagged."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-                                                  Aar Field), midway to Mobale, 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. At 2258 the tower transmitted the fol                                                      Examination of the aircraft, NC-88897, lowing weather observation "Ceiling 300                                                   indicated that considerable damage had resulted from the airplane flying throngfeet 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, and in each of the three landing Moisant Airport. A Chicago and Southern                                                   gear struts. Propellers No. 1 and No. 2 airliner, ar. that time, was standing by                                                  were out of "track." A three-inch tear on the airport waiting for Pan American                                                   was found in the left de-icer boot, and to land/ Flight 702 was instructed that                                                   a four-inch hole was found m the left should he miss his approach, he was to                                                    flap. The wheel nacelle doors were continue on a westerly heading,                                       and                 dented and damaged, and the left main climb to and maintain 2,000 ieet* Flight                                                  landing gear bungee system including ca- 702 missed his approach, struck trees                                                     bles, springs, and bracket, was broken,near the airport boundary, and shortly                                                    The right hand "sense" antenna, and the after reported trouble with engines No. 1                                                 rear short "marker" antenna were miss- and No. 2. At 2313 Chicago and Southern                                                   ing. Oil cooler cowlings for Engines was instructed to return co the hangar No 1, No 2 and No. 3 were dented and in order to allow Pan American to make                                                    chokea with Spanish moss. The right in- an emergency landing.                                Although an emer-                    board fuel tank was raptured. The right gency landing was requested, downwind,                                                    landing light assembly was missing, andon Runway 28, it is not established that                                                  the right horizontal stabilizer was bad- another approach was made, however, the aircraft did remain in the New Orleans                                                    ly' damaged Prior to the accident thearea 20 to 25 minutes after rne accident.                                                 aircraft was entirely airworthy and At 2321 Flight 702 was issued a                                                           properly certificated. There was no evi- dence to indicate that any mechanical clearance to Memphis. Captain Adger,                                                      failure occurred before the airplane however, requested clearance to the struck trees. nearest landing place because of engine                                                    The crew was qualified and properly trouble. Engine No. 1 was shut down and                                                   certificated to make the flight                 Captain the propeller feathered; Engine No 2                                                      Adger bad a total of 3,146 flying hours, was                           reduced to 20    inches      ITT  anifold      pres-        1,000 of which were m DC-4 equipment. sure because of excessive oil temperature                                                 First Officer Lutz had a total of 2,926 Observation was incorrectly quoted by towp~ It                                            flying hours, 164 being m DC-4 equip-shoulc we been -stated "Celling ind^ fin It- 200 rv er-                                   ment. rant, low*3? broken, etc , " ratber ^han "Celling inlef-                                           The U. S. Weather Bureau forecast for inite 200 overcast., lower scattered * /s the stated lr, it would mean scattered clouds under Che                                       New Orleans, December 19, 1946, indi- 200 foot overcast                                                                         cated that the ceiling would drop from ^Towp' should ha/c stated "Celling Indefinite. 300 feet broken, rather than "Celling 300 feet ordken "                                      6,000 feet at J630 to 800 feet at 0000,--- 17665 3 and that the visibility would be re-        and such a finding is not essential in stricted from 8 miles at 1630 to 4 miles    determining the probable cause of this at 0000. The celling at Lake Charles was    accident. predicted to drop to 300 feet, and the      Discussion visibility to one mile. MoblJe was ex- pected to remain above 1,500 feet with      Though good weather was expected along the visibility 4 miles or better; Mem-      the entire route, tnorough study of the phis was expected to remain above 2,000     weather data and charts available prior feet with a visibility of 7 miles or        to take-off from Merida. Mexico, would better, but icxng was forecast at 2.000     have indicated to the flight crew that feet, lowering to near surface after        instrument conditions would be encoun- dark. The forecast naue by Pan American     tered before their arrival over New Or- personnel was substantially the same as     leans, and Captann Adger was forewarned that of the U- e. leather Bureau summa-    of a rapidly falling barometer by rized above.                                Overseas-Foreign Airways Communication Pan American airport specifications         Station, New Orleans, when 25 minutes for Moisant Airport, in effect December     from destination. A warm *waven had 19, 1946, provided for night landings       formed on a previous cold front south of not below the minimums of ceiling 400       the Texas coast. This developed into a feet, visibility 2 miles, or filing 500     storm center which moved northeastward, feet, visibility one mile. The first two    causing low ceilings and rain in the approaches of Flight 702 were made when     Gulf states. The warm front moved more the weather was reported to be better       rapidly than predicted, and was located than the above stated minimums. Between     between New Orleans and the Gulf coast the time of the second approach and the     at the time that the flight was in the time that Flight 702 flew through the       New Orleans area. Weather conditions, trees, however, Moisant Tower transmit-     similar to those at New Orleans, should ted at least two weather observations       have been expected at Lake Charles and reporting the ceiling to be at 300 feet     Mobile, yet Lake Charles and Mobile were or below, and the visibility to be 2        both designated as alternates. miles. At least one approach was made       The Moisant Airport control tower log after the ceiling was reported below        indicates that Flight 702 received re- minimums, and after the pan American        quested information from the tower. Had dispatcher at Brownsville advised Flight    a listening watch on tower frequency 702 to proceed to Memphis. Captain Adger    been continually maintained by the pi- decided, however, to remain in tne New      lots, the transmitted weather informa- Orleans area.                               tion and altimeter settings also should There was no evidence of malfunction-       have been received. If, however, the ing of radio equipment or flight instru-    observations transmitted during the first ments. The altimeters were removed from     two approaches were not received, safe the aircraft, tested by Pan American        practice would have required Captain personnel, and showed no error greater      Adger to secure a full and complete than the tolerance allowed to a manufac-    weather report, including an altimeter turer for a new instrument. Two possible    setting, before starting any third ap- sources of altimeter error existed. If      proach . the static selector valve had been in       Evidence indicates that Captain Adger the alternate source position, it would     was fully cognizant of a lower than min- have resulted in an error of as much as     imum ceiling in the vicinity of Moisant 100 feet. The second source would have      Airport. The traffic controller reported resulted from the failure of the flight     that Captain Adger stated* You gave me crew to make the necessary altimeter        a bum steer on weather. I am down to 300 settings. From the time that the flight     feet and am not contact." He was also first contacted Moisant Tower to the        observed by tower personnel to fly as time of the accident, the altimeter set-    low as 50 feet above the trees. It ap- ting dropped .12 inches which would have    pears, therefore, that the third ap- resulted m the instrument reading           proach, at which time the trees were approximately 120 feet higher than the      struck, was made when Captain Adger knew actual altitude. There is no reliable       that the ceiling was below minimum, and evidence, however, from which a finding     at a time when no mechanical malfunc- can be made concerning these possibilities. tioning existed. Captain Adger referred to the proce-                                                                        4. No mechanical failure occurred to dure he used to land at Moisant Airport                                                                     the aircraft or any of its componentsas a "New York approach." He held a                                                                         prior to the time of the accident. heading so as to arrive to the right of                                                                     5. Frequent weather observations were the intended runway for landing, and                                                                        transmitted by the tower from                                                      the time after passing the airport boundary cir-                                                                     tne fJighr first reported over                                                     the New cled so as to land into the wind on that                                                                    Orleans range station until it                                                     collided runway. The object of such an approach                                                                      with trees. was to keep the field in sight while                                                                        The pilot did not make a                                                           standard n:           aneuveiing underneath the overcast. An                                                        "straight in instrument approach, but examination of Exhibit 2D, which is a                                                                       attempted to circle underneath the over- chart of Moisant Airport on which Cap-                                                                      cast for a landing into the wind. tain Adger drew his flight path, will                                                                       7. The third instrument descent and show that no precise consistent pat-                                                                        approach for landing was made after the tern was flown after passing over the                                                                       ceiling had been reported below minimum, range station toward the field, and that                                                                    and after the Pan American dispatcher at no standard missed approach procedure                                                                       Brownsville advised proceeding to Memphis. was used. Though he succeeded in de-                                                                        8. The pilot knew that the ceiling scending below the overcast over the                                                                        was below minimum before making his airport, he was unable                                                               to align the air-      third approach at which time he collided craft for                                    a landing on                            an> runway.            with trees. The flight then proceeded to Mobile, Alabama, and landed safely. F ind ings 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                                                                          lot's deliberate descent through an were properly certificated.                                                                                 overcast to a dangerously low altitude 2. Weather data and charts available                                                                        m an attempt to land despite his knowl- to the crew prior to departure from Meri-                                                                   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. ment conditions would                                                             be encountered in the New Orleans area,                                                             and that weather conditions similar to                                                             those in New Orle-                                                                       Is/ J. M. LANDIS ans could be expected                                                             at Lake Charles                                                                          /s/ OSWALD RYAN and Mobile.                                                                                                                                                                Is/ JOSH LEE 3. Lake Charles and Mobile, both mthe same storm area as New Orleans, were                                                                                                      Branch,         Member         did not take part in designated as alternate airports.                                                                                                           the decision.---17665From PilotManuals.com / RareAviation.com Investigation and Hearing                   At the time ol the accident he had logged No notification of this accident was        I 3.146 hours. 1.000 hours being in DC-4given by Pan American Airways to the        i equipment, and 350 hours being instru- ments. Captain Adger held an airline Civil Aeronautics Board. First knowledge    transport rating. Certificate No.162003. was received from the Chief, CAA Air        He had been given a route check into Carrier Inspector for the Second Region     I 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 Americans Flight 702 nad "met with an      H. Lutz, the co-pilot, age 30. was em- incident." Foil particulars were re-        ployed by Pan American January 4, 1943. quested by telegram. On December 23,        He held an airline transport rating, 191'1. the Operations Manager for Pan       Certificate No. 129485. When hired, he American Airways m Miami submitted          had a total of 1,500 hours accumulated information to the Civil Aeronautics        in the U* S. Army Air Corps, and at the Board, Atlanta office, that Flight 702 nao. struck trees while approaching Moi-    time of the accident he had logged 2,926 sant Airport for a landing, and that the    hours, 162 in DC-4 equipment, and 370 damage resulting was extensive enough to    hours instruments. Both pilots received 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 was initiated immediately in       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 1938. 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 Vorld 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 ol 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.---17665 !i ho. 1-0053 uCIVIL AERONAUTICS                                         BOaRDAdopted:                                                                       June 18, 194-8                                                                                      Released June 21. 194-8PAH AMERICAN AiRWAYS, INC.--- MAYADINE, SYRIA---JUNE 18, 19'47The Accident                                                                                                                                    Habbamya, Iraq Shortly after this re- Pan American Vpwv., Flight 121, a                                                                                    port Habbaniya Tower was advised by the Lookheed Cons-uellr uion, Model 049, NC-                                                                                                        flight that its approximate position was 88845, er route from Karachi India, w                                                                                                           over Bagdad at an altitude of 10,000 Istanbul, Turkey, crashed during a forced                                                                                                       feet, and the flignt requested Habbaniya landing at night in the desert near                                                                                                             Tower to inform the civilian airfieldsMayadine, Syria, at 2340, 1 June 18, 1947.                                                                                                      in their area that the aircraft was pro- Seven of the 26 passengers, and 7 of the                                                                                                        ceeding with the use of only three en- crew of 10 were fatally                                                                                                 injured. The            gines to Istanbul Habbaniya Tower re- aircraft was destroyed                                                                                                 by impact and            plied, stating that no airfields would be fire                                                                                                                                            open until dawn, and suggested that an emergency landing be made at Habbaniya History of the Fl ight                                                                                                                          Flight 121, however, affirmed its inten- tion to continue, and added that if it Flight 121 deper ted from Karachi at                                                                                                            we^e impossible to reach Istanbul, a 1537 June 18, 1947, for a return trip to                                                                                                        landing would be made at Damascus, Syria the United States. The climb to the                                                                                                             Habbaniya Tower answered, at 2225, that cruising                                                             al ti tude                 of 1           ,500             feet was        all airfields in the Damascus area were routine,                                                          and the flight was proceeding                                                 closed until 0400 and again suggested "direct                                                          to Istanbul, the first intended                                               that the flight land at Habbaniya. Thepoint of landing, estimating its arrival                                                                                                        flight again stated that it would con- there to be 0208 the next day. Five                                                                                                             tinue to Istanbul, but that it would hours after take-off trouble developed in                                                                                                       turn back to Habbaniya if it experienced the No. 1 engine, and the No. 1 propeller                                                                                                       any more trouble. was feathered. The captain, J H. Hart,                                                                                                          Contemporaneous with this communica- decided to continue to Istanbul with the                                                                                                        tion to Habbaniya Tower the flight sent use of three engines                                                                                        however, it soon                    a message, received m Karachi, and re- became evident that                                                                                        at an altitude of                    layed to Damascus, requesting that 18,500 feet the airspeed obtainable was                                                                                                         Damascus Radio be alerted to stand by, not sufficient to provide adequate cool-                                                                                                        and that the airport be opened. At 2308,ing for the engines, even though climb                                                                                                          June 18, Damascus Radio was on the air, power was applied. Power was accordingly                                                                                                        and the field was opened                                           as had been re reduced and altitude was gradually lost.                                                                                                        quested. At 17,500 feet the engines still over-                                                                                                          At approximately 2300                                               the flight re- heated and the descent was continued to                                                                                                         ported its position to be                                           75 miles north 10,000 feet.                                                                                                                                    west of Habbaniya at 10,000 feet                                                  Fif-At 2140, approximately one hour after                                                                                                           teen to thirty minutes later the purser the failure of engine No 1, the flight                                                                                                          seated in the passenger cabin noticed advised its company radio m Karachi of                                                                                                          that the fasten seat belt---no smoking the engine trouble, following which it                                                                                                          sign had come on, and he immediately reported its 2200 position. This report                                                                                                         started to awaken the passengers so that placed the aircraft at 14,000 feet, 50                                                                                                          they might fasten themselves in their miles east of Bagdad, Iraq, and 90 miles                                                                                                        seats. Suddenly, the                               entire cabin be- east of the Royal                                                                                 Air Force                       Field at      came illuminated from                              a fire which had started m Zone 1 of                                the No 2 engineAll times referred to in this report are Greenwich                                                                                              nacelle A report of                                this fire was re- Meridian 7Ln and based on the 24-hour clocK. (Time                                                                                              ceived at 2330, by the Habbaniya diree of the accident, Mayadine, Syria, local time 1 40 a in June 19 )                                                                                                                                       tion finding station, at which time the 2flight was reporting a position of 34 38    Part of the nacelle had broken free from degrees north and 41. 05 degrees east, a    the engine and was located a short dis- point 170 statute miles northwest of        tance away An examination of the engine Habbaniya, and 290 miles northeast of       and nacelle showed that severe fire had Damascus Immediately after the fire         extended from Zone 1 through Zones 2 and started in engine No. 2 a rapid descent     3, and that the most intense area of was made for the purpose of crash land-     burning had been along the upper inboard ing the aircraft, and six to seven min-     side of the nacelle It was impossible utes later on the landing approach the      to determine the cause of either the fire No. 2 engine fell from the aircraft The     or the failure of this engine at the wing m the area of the No 2 engine,         scene of the accident. Consequently, the however, continued to burn intensely.       No. 2 engine was returned to the United Less than a minute after the No 2 en-       States where the necessary facilities gine fell from the aircraft a wheels-up     were available for detailed examination. landing was made on relatively smooth,      A considerable amount of both the air- hard-packed desert sand.                    craft struct.re and the engines was car- The left wing tip made the first con-       ried away by native souvenir hunters be- tact with the ground, then the No 1         fore the aircraft could be satisfactorily propeller, and then the left wing at the    placed under guard, and many parts of No 2 engine position The impact tore        engine No. 2 were not recovered However, the left wing from the fuselage near its    the nose and power sections of the en- root, and caused the aircraft to ground     gine with all cylinders attached were re- loop violently to the left During the       turned to the United States f\ complete course of the ground loop the aircraft      teardown of these engine sections was turned around its longitudinal axis 180     then accomplished. degrees, skidded backwards for a distance   It was found that the thrust bearing of 210 feet, then came to rest m flames     assembly was almost entirely destroyed, 400 feet from the first point of impact,    and was marked with signs of excessive and headed opposite to its course of        frictional heat The ball bearings and landing                                     roller bearings with their retainers and Investigation                               races were badly mutilated. The oil seal rings for the governor oil passage were With the exception of the empennage         found normal except that they also showed and parts of the wing, the aircraft         signs of heat. The oil transfer ring structure was largely destroyed by fire.    sleeve for the propeller control oil pas- At the trailing edge of the wing the        sage was found normal except that the oil fuselage was broken in two, and approxi-    seal rings had worn marks over the open- mately 200 feet from the main body of the   ings of the oil transfer passages wreckage, the left wing was located on      The No 18 exhaust cam follower roller the landing path of the aircraft. The       was found to be worn flat on its circum- left main landing gear had been torn from   ference to the extent of being 1/8" be- its mounting, however, the right main       low original contour. With the excep- landing gear and the nose wheel, though     tions of the Nos 8, 10, 12, and 14 cyl- burned, were found in the retracted posi-   inders, all cylinders showed considerable tion The position of the trim tabs          fire damage with major damage being con- could not be determined Flaps were in       centrated in the area of cylinders Nos the 50 percent down position and the        1, 3, 5, and 18 All piston heads showed landing lights were found to have been      signs of striking the exhaust and intake extended                                    valves. No difficulty was reported with en-         A considerable amount of internal dans- gines 3 and 4, accordingly no detailed      age was found in the propeller reduction examination was made of these engines       gear assembly, and the power section As Engine No 1 was examined at the scene       indicated above, the accessory section of the accident, and it was found that      for this engine was not rert/ * red from the exhaust rocker arm for the No 18        the scene of the accidm* for detailed cylinder had broken as a result of fa-      examination tigue It was this break that caused the     The No. 2 engine, a Wright 745C18BD3 unsatisfactory operation of the engine.     engine, Serial No. 60336, had a total of The No 2 engine was located one mile        1,588 hours since new, and 509 hour<> back of the wreckage on the flight path     since its last overhaul During the course of the eastbound flight from La-                                         knokn events occurring during the course Guardia Field, New York, to Gander, New-                                        of the flight provided any reason fro:                                                     IIfoundland, the flight engineer observed                                         which the crew could nave expected other <2                                         than normal operation of engine No. 2. a drop of 10 BMEP in chis engine, and so the No 2 propeller was feathered                                             The extensive damage found in the After landing at Ganaer, the spark plugs                                        thrust bearing for the No. 2 enginefor the No. 18 cylinder were changed, and                                       clearly indicated that this failure pre- the oil sump plug was examined and found                                        ceded the fire So extensive was the to be free of' any foreign matter The                                           damage to the propeller shaft that proper flight then departed fo^ Santa Marla,                                           alignment was impossible However, it Azores, and London, England Again a                                             has not been possible to determine over drop in BMEP on the No 2 engine was                                             how long a period of time this failure noted, so the flight returned to Gander                                         progressed, but it is hignly probable A piston ring failure was discovered                                            that tne crew became aware of vibration which was corrected by replacing the No.                                        and erratic                         engine speed sometime prior 18 cylinder ana piston assembly When                                            to the time                         that the fire occurred. the flight arrived at Istanbul, the flight                                      The fire                            in Zone 1 of the No 2 engine engineer reported that tne No 2 engine                                          was intense                         and               sustained The only was again giving t^ouole, this time                                             possible source                                       of fuel to support such areading 15 BMEP 3 ow ac rated power An                                          fire was engine                                       oil This oil could have examination of tne engine disclosed that                                        been fed to the                                       fire eitner tnrougn the the left magneto breaker noints were                                            sain engine case or its actached cylin- closed They were ^eg apnea., and the en-                                        ders, or through a rupture in tne pro- gine then operated normally No further                                          peller feathering line                                                   or fitting No malfunction of this engine was experi-                                          breaVwas found in the                                                    engine case or itsenced so far as is known until the fire                                         attached cylinders. was observed m the No 2 engine on the                                           The markings of the                                                      oil seal rings return flight to the United States                                              found on the oil transfer sleeve showed No evidence was found in tne examina-                                           that the oil seal rings had moved for- tion of the propellers                                 which would indi-        ward as a result of the thrust bearing cate other than normal                                 operation                failure, and that they effectively re- stricted the oil transfer holes to the Discussion                                                                      extent of covering approximately 7/8s of So far as is known                                     the difficulty ex-       the openings Such a restriction would perienced with the No                                  2 engine at Gander       have resulted m excessively high oiland Istanbul was not associated with the                                        pressure in the feathering line had any fire. When the piston ring failure in                                           attempt been made to feather tne pro- the No 18 cylinder was discovered at                                            peller . An attempt to feather the No 2 pro- Gander, the cylinder and piston assembly                                        peller was m all probability made The was replaced An examination of the oil sump plug gave no indication of any in-                                         flattened exhaust valve cam follower ternal damage, and no further trouble was                                       roller in itself might have accounted for at that time experienced in the operation                                       an erratic BMEP reading An erratic pf that engine It would appear, there-                                          power output in conjunction with the fore, that all required maintenance had                                         known progressive failure of the thrust been performed, and that no reason ex-                                          bearing would have resulted in a fluctu- isted to anticipate any further diffi-                                          ating engine speed, and considerable culty At Istanbul closed breaker points                                         vibration Such a condition, possibly were found in                    tne left magneto for the                       becoming progressively more intense, No 2 engine,                     which accounted for the                        would certainly have been ample reason loss of power                    developed by the No 2 en-                      for attempting to feather the No. 2 pro- gine prior to                    the flights arrival there                     peller When the breaker points were regapped the                                       As stated above, the oil seal rings engine operated normally, and again no                                          during the course of failure of the reason existed to anticipate further en-                                        thrust bearing moved forward and effec- gine trouble Therefore, none of the                                             tively sealed the openings in the oil transfer sleeve, thereby blocking the passage of oil from the feathering pump 2              --- Brake Mean Effective Pressure ---                                               into the propeller dome. It is Highly 792.000 x brake horsepower                                                      possible that a surge of excessively high Displacement x Revolutions per Minute l0'80 ln oil pressure in an oil line which was       1. The aircraft, the carrier, and the being subjected to severe engine vibra-     crew were properly certificated. tion may have been sufficient to cause a    2. At the time of departure fromrupture either in the line itself or at a   Karachi, India, the total weight of the fitting. Had such an event occurred, a      aircraft was less than the maximum allow- large volume of atomized engine oil,        able, and the load was properly distri- highly inflammable, would have been         buted with respect to the center of sprayed on the front exhaust collector      gravity. ring which would have most certainly re-    3. Approximately 5 hours after take- sulted in the fire which was experienced    off from Karachi, and while cruising at m this case. This theory of engine fire     an altitude of 18,500 feet to Istanbul, is supported by the fact that the cylin-    Turkey, the No. 18 exhaust rocker arm on ders and engine cowling in the inroediate   the No 1 engine broke as a result of vicinity of the propeller feathering line   fatigue, and the No. 1 propeller was showed the most intensive fire damage,      feathered and furthermore, no break was found in      4. The aircraft continued toward fhe wells of any cylinders or in the mam    Istanbul, descending to 10,000 feet in case from which the oil could have es-      order to provide adequate cooling for the caped from the engine.                      three operating engines. High engine operation temperatures may       5. Approximately 3 hours after the have contributed to the failure of the       loss of the No. 1 engine the thrust bear- No. 2 engine thrust bearing. However,        ing for the No. 2 engine failed, which under the known conditions of flight,        resulted in blocking the passage of oil high engine operation temperatures would     from the propeller feathering motor to be normally expected and would not in        the propeller dome. tneraselves be any special reason for        6. Subsequent to the failure of the alarm or anticipation of further engine      No 2 engine thrust bearing, engine oil trouble. The decisions made by the pilot     caught fire in the upper inboard region in this case were consistent with known      of Zone 1 of that engine and extended test and operational data for the en-        through Zones 2 and 3 gines in the aircraft, and he could have     7 Before an emergency landing could reasonably expected after descending to      be effected the No. 2 engine dropped fron a lower altitude that there would be suf-    the aircraft and the fire continued m ficient cooling for normal temperatures      the wing panel. of the three operating engines               8. The aircraft landed on hard-packed Had the crew experienced difficulty          desert sand, ground looped violently, and with engine No. 2 other than high tem-       came to rest in flames. peratures, certainly a landing should        Probable Cause have been effected at the nearest avail- able field. However, it is not known         The Board determines that the probable over how long a period of time tne pro-      cause of this accident was a fire which gression of failure of the No. 2 engine      resulted from an attempt to feather the thrust bearing was extended. If this         No. 2 propeller after the failure of the period of time was short, the crew may       No. 2 engine thrust bearing have had little warning, and no oppor- tunity to anticipate the loss of that en-    BY THE CIVIL AERONAUTICS BOARD gine Accordingly, no criticism can be made of the decisions that were made in      Is/ JOSEPH J O'CONNELL, JR this instance.                               Is/ OSWALD RYAN Findings                                     /si JOSH LEE On the basis of all available evi-           Is/ HAROLD A JONES dence, the Board finds that                     Adams, Member, did not participate. --- 19366 See our selection of aviatioon documents at RareAviation.com Supplemental DataFl ight PersonnelThe Civil Aeronautics Board was noti-                                               Captain Joseph Hall Hart, age 40, of fied of the accident during the morn-                                               Greenwich, Connecticut, was pilot of the air-ing of June 19, 1947, and an investi-                                               craft at the time of the accident, and pos- gation was immediately initiated in                                                 sessed a currently effective airline trap- accordance with the provisions of Sec-                                              port pilot rating Until the date of the tion 702 (a) (2) of the Civil Aeronau-                                              accident, he had accumulated a total of tics Act of 1938, as amended An acci-                                               12,768 hours flying time, of which 1,009 dent investigator was ordered to pro-                                               were obtained in Model 049 aircraft First ceed immediately and he arrived at the                                              Officer Roberjt Stanley Mc-Coy, age 25, of scene of the accident June 23 He was                                                Flushing, Long Island, New York, was co- assisted in the foreign phase of the                                                pilot of tne aircraft at the time of the investigation by Civil Aeronautics Ad-                                              accident ana possessed a currently effec- ministration, Pan American Airways, Lock-                                           tive airline transport pilot rating He heed Aircraft Corporation, and Wright                                               had accumulated a total of 3,178 hours, of Aeronautical                Corporation personnel                   The             which 674 had bee^ in Model 049 aircraft subsequent domestic phase of tne investi-                                           Both pilots were properly certificated andgation was conducted in New York, New                                               the captain was qualified over the route York, with the assistance of other per-                                             Robert B Donnelly, age 33, Bay side, Long sonnel of the Safety Bureau staff A                                                 Island, New York, was flight engineer and public hearing was ordered by tne Board                                             held an A &, E and Flight Engineers Cer- and was held m New York City, August 5,                                             tificate He had accumulated a total of 6, and 7, 1947                                                                      799 hours as Flight Engineer on Constel- lation equipment iir Carrier                                                                         The AircraftPan American Airways is incorporated                                                       NC-88845, a Lockheed Constellation, under the laws of the State of New                                                  Model 049, had been operated a total ofYork and has established its head-                                                  2,645 hours since original manufacture Itquarters in New York City Pan American                                              w'as equipped with four Wright 745C18BD3 en- Airways was operating under a cur-                                                  gines, with Hamilton Standard propellers rently effective certificate of public                                              installed The Nos 1, 2, 3, and 4 engines convenience and necessity and an air                                                had been operated a total of 1,601 hours, carrier operating certificate issued,                                               1,547 hours, 1,078 hours, and 1,734 hours, pursuant to tne provisions of the Civil                                             respectively, and all engines had accumu- Aeronautics Act of 1938, as amended                                                 lated 251 hours, 568 hours, 601 hours, These certificates authorized Pan                                                   and 241 hours, respectively, since the American Airways to engage in the trans-                                            last major overhaul At the time of de- port of persons, property, and mail                                                 parture from Karachi, the total weight between various points m the United                                                 of the aircraft was 187 pounds less tnan States and abroad, including the route                                              the maximum allowable, and the load was between Karachi, India, and Istanbul,                                               distributed with respect to the center of Turkey.                                                                             gravity witnm approved limits--- 19366                                                                                          (I) SA-151                                                                                                              File No. l-OOftCIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORTAdopted: March 29, 1948 Released: March 30, 1948PAN AMERICAN Al RWAYS---FLOYD BENNETT FIELD, BROOKLYN, NEW YORK- SEPTEMBER 20. 1947The Accident                                                                             minutes later Mr Robinson noticed that Pan American Airways' Flight 131, a                                                      tne right auxiliary fuel gauge Indicated C-54-DC airplane, NC-88911, executed an                                                  not 40 gallons, but 100, and that it was emergency landing at Bloyd Bennett Field,                                                visibly increasing even though no fuel Brooklyn, New York, at approximately                                                     was at that time being transferred The 1823,; September 20, 1947 No injury was                                                  No. 3 main 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 Fl ight                                                                   the fuel system, Mr Robinson operated Pan Americans Flight 131 departed                                                       all engines from the left main tanks (1 and 2), turning on all the cross feed from Bermuda at 1358, September 20, 1947,                                                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 Carl 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 few 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. ill Limes referred co herein are Eastern Standard                                        Two minutes later the fire warning andjbased 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, 1 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 --- 18624                                                                                                   (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                                                          II                                      ade 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                                                          "VHP1 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                                                                                    II    dies 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-            It                                       ain 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 ongear llgnt 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 milling, 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-                              ment was dispatched, and as Flight 131 glnes 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 flrve minutes later, through Eastern Air Lines* 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"3 from the U. S.                                                           position for a straight-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 "CWrt 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 ?nCk"---Abbreviated for continuous wave transmission                                              the engine,                                                        the propeller dome becoming of code rather then 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 h&d 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 Otnerwise, 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 Investigation                                                      auxiliary 28, and the right auxiliary 7 gallcis No fuel was found in the No. 2 Considerable 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 confloed 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 ha.s 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. Below this "bus," also mounted on the                              Electrical components including volt- front wing spar in the No 3 engine na-                             age regulators, reverse current relays, 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. 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 tqe 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 ---------                                                          a mass 1 5 times that of the pulley This "bus" connects all four generators to the bat-                bracket found in NC-8S911. Tne first teries See Appendix II for diagrams of this installa-              contact was made intermittently, which tion- 9 A detailed report of the damage found in zone 3 of               resulted in a considerable amount of engine nacelle 3 will be found in Appendix III of this             arcing. Melted particles of magnesium report                                                           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 ii agnesium 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 sisted 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-54fs, 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 bythe "bus" by a metal conduit or a rubber                                           the company as a navigator as well as a shield                                                                             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 thefactured 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-54fs 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 agency, it is not able to give as com-               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 cumulo- .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      Discussion 8280 kcs, than on 500 kcs., and it is some- 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 kcs by the Federal    tained in the left auxiliary tank prior Communications 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 fll^it. vessels and aircraft, particularly those    Tne only possible cause of fuel pressure of foreign registry, use 8280 kcs. as a     fluctuation m 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   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     their 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 kcs< 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 back 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 to 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. It is, of course, virtually       the leads from the master switch to the impossible for any one operator to lister*  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 Ifaese leads were found grounded All messages concerning the distress were j  at che tune 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-54s disclosed inthe 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 n 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 in 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 have 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                 Theimmediate 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 Accident Investigation Report                                                       7 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.        ing agent was installed in zone 3 of the Findings                                    engine nacelles in the aircraft 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 Company's 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-54's                             or crew. 4 Electrical arcing occurred between        Probable Cause the "bus and an engine control pulley 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 m 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      BY THE CIVIL AERONAUTICS BOARD wiring routed through the nacelle, in particular, the magneto ground wires for    Is/ OSWALD RYAN engines 3 and 4. 6 The magneto ground wires, for en-         Is/ 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                                                         CarburetorEngine Driven Pump                                                                     Engine Driven Pump                                                                                  Engine Driven PumpEngine Driven PumpEire wall                                                                              Firewall                                                                                            Fire wall                                             FirewallEmerg Firewall                                                                         Emerg Firewall                                                                                                                        Emerg Firewall Shutoff Valve                                                                          Shutoff Valve                                                                                                                         Shutoff ValveStrainer                                          S trainer                                            L Aux Tank Selector                          R Aux Tank Select                         Strainer                                    S trainer Valve (3 Postion)                            Valve (3 Position)AppendixCross feed                                                                                         Crossfe^d                                             Cross feed                                                          Cross feed Valve                                                                                            k Valve                                               Valve                                                                 Vai veTank Select                                            Tank Select                                                                                                       Tank Select                                Tank Select Valve                                                                                                                                                                    Valve                                      ValveTank Drain                          Tank Drain                                                           Tank Dram                               Tank Drain                            Tank Dram                      Tank DramI Main Tank                             Left Auk Tank                                     2 Mam Tank                                                                      3 Mom Tank                           Right Aux Tank                  4 Main Tank Cap 495 Gal                                      Cap 4 31 Gal                       Cap 508 Gal                                                                                 Cap 508 Gal                              Cap 4 31 Gal Cap 4 95 GalFIG 2 FUEL SYSTEM                 DIAGRAM- SCHEMATIC C54B-DC 4                 TANK SYSTEMPREPARED BY PAAFrom PilotManuals.com / RareAviation.com M inches               S Inches To Middle             To Inboard Bracket               SupportAppendix IIU.ICD      SIDE VIEW            FRONT VIEW The damage which occurred in the                 No.     female receptacle insulation and male 3 nacelle; Zone 3, has been divided               into    pins . the following areas                                       7. Lugs and wiring associated with re- verse current relay in firewall junction io The        region immediately behind      the     box snow discoloration. Wire from equal- firewallo                                               izing resistoi to ground shows scorched 2. The sides and top of the nacelle                       insulation. egicn                                                  8. Feathering motor power wiring in-3o The front face of the spar region.                     side the firewall junction box showed 4. The under wing wheel well fairing                      evidence of neavy currents at the sole- region                                                   noid . The material which follows has beenfurther 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 structurer                              (outboard rear side of                         nacelle) for a (c) Damage to the electrical syste                        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 Firewall                                    board nacelle gusset* Fluid Systems and Plumbing                                2 Rubber in gang line clamps Glis-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 fro:                this side of firewall0                                         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 i 1/2 from un- strap pad burned out. Outboard strap                      ion in line. This is in same location as pad burned and blistered.                                 carburetor alcohol line in the previous 2. Upper landing gear door fitting                        item. 5. Three deicer air pressure lines bent upward (probably in landing) .                       burned across top of nacelle over tires. Landing gear door mechanism spring                        Severe burning from entrance at nacelle stretched permanently and overheated. (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 side of nacelle from this point as it branches out. Wire                  (10n). Outboard of nacelle two lines insulation charred about 12 beyond bare                  burned off at side of nacelle completely wire.                                                     for 9n 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 No 3 blistered and charred to nacelle junc-                    engine (not in use, but containing engine tion box.                                                 oil blocked off) burned or Broken top ena 3? Generator field and volt-ammeter                       off including cap and snows 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 line and little if any oil was released    nacelle burned and charred 2/3 back froitf from It. No oil in line.                   firewall. From this point to terminal Structure                                  strip at spar, wire was bare. Wire loose 1. Nacelle longitudinal just outboard      from terminal strip which is earned 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. Rearmost nacelle frame (transverse      noids . 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    Front Face of Spar Region burned out except for stubs attaching to 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 5. Upper outboard pulley bracket           outboard sldd 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 Q 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) welded 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- 11. 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 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 cables8. 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 breaKo 9. Main spar face pulley bracket                                      8 Terminal 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 Plumbingwas pulled out of its support bracket                                  1. No. 3 main tank outlet hose at which was partially burned Away                                       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 extending                                                   upper end of line below wing skin fit- beyond side of nacelle 6" on outboard                                                     ting, line was severely burned and side (this was not protected by nacelle                                                   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 bottom 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 burned bus           2. Wire bundle from under wing junc- 7" outboard                    to 3" inboard of bus separa-            tion box aft to rear main strut attach 11 on. (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 extensionner 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--- 18824 From PilotManuals.com / RareAviation.com 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. 1-0099-47CIVIL      AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: March 21 f 1949 Released March 21, 1949PAN AMERICAN A S RWAYS---ANNETTE ISLAND, ALASKA---OCTOBER 26, 19U7The Accident                                                                                                       Island at 1338 after a routine trip. At approximately 1345, * 1 October 26,                                  Earlier, at 1326, the company radio at 1947,                                           Pan American Airways Flight 923,                               a  Annette Island had transmitted a weather DC-4,                                           aircraft iNC 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, rain, crew 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 in respect                                                                             mountainous terrain east and northeast to the center of sravitv                                                                                            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 celling 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 Sbutheast at 18 knots A cold type oc-                                                                               to the airport. In response, Annette clusion or 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 times noted herein are Pacific Standard and                                                                               L See Appendix 1 based on. the 24-hour clock--- 16577                                                                               (1) 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 theby 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. Investigation                                              The Fluxgate Compass was found with 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 m 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 in 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- ings 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---4 type airplanes He about 145 degrees at the time of impact.                   had been employed as a pilot in 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 m 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 wasS Coast and Geodetic Survey charts, reissued               instrument time, he received an airline May 19, 1938, and che Aeronautical charts available to     transport pilot rating. He was then the crew of Flight 923, showed the   elevation of Tamgas Mountain co be $ 610 feet     A re com pu tat! on   sent on a flight of 66 hours to Trini- of the elevation subsequent to the   accident showed it    dad, Britisr ftest Indies, in a DC-3 air- to be 3, 596 feet, or 14 feet lower  than the published elevation                                                  plane, following which he returned to See our selection of aviatioon documents at RareAviation.com Accident Investigation ReportSeattle 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 the 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 checx 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                                                                     celling 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 in 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 sical                                      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 flights arrival overtaken                                     August 15, 1947 Mr. Foster had                                    Port Haray. From there until it reached had a                                     48-hour rest period immediately                                   Annette Island, the flight was either mpreceding his departure from Seattle                                                      o                 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 m March                                                                      lence Winds progressively increased m 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 Mon sen 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. Ac 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                                                                       a* Upon the flight's 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- H 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 U southeast 28, strong gusts, altimeter       still approximately 100 miles west of29.57, overcast estimated at 2600           Annette Island. The original forecast The Army pilot who landed at Annette        was in error also in 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 fet, which grew progres-    ized, he would have forecasted much more sively more severe down to about 400        severe turbulence at low altitudes in 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 rain.                           Seattle Approximately 3 hours after the last        Analysis transmission of Flight 923, a non- 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 flights arrival.     the time originally calculated. But This forecast was not in accordance with    this does not appear in itself to be the forecasts of the United States and      significant. Apart from turbulence, the Canadian Heather Bureaus. At 1'229, 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 m the vicinity of Annette, patched a revised forecast "Expect oc-      would have been to drift the airplane clusion 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 ram, 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 Accident Invest * gat ton Reportto warn the c^ew of Flight 923 of the          4 Routine nositio" ^ro^ts *ere re- very condition which t^ey reported in         ceived from me flight until 1333 v-hen it their last transmission                       reported being ove" tne Annette IslandThere 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 may have been se-       doning its approach due to extreme tumu- vere icing which resulted in a loss of        lence, and that it would proceed to Ju- control There are other possible theo-        neau. 7\o further co^mum-at_on was re- ries, but it remains impossible to ex-        ceived forr t^e flight plain why the flight was unable to stay       6  Tie ai^c^aft 1 as o a trie ^eaai^g on the proper side of the radio range,        of 145 degrees and i^> a 20 degree climb- and why it was flying a neading of 145        ing attitude at time of impact. degrees Outside of the fact that severe       7  The flight c^asned on tre "oth turbulence and icing conditions existed       side of rat. Tam gas at a point eigne miles over Annette through wnioh toe flight haa     east of tie Annette Island airport, to descend, there is no i eal evidence to     eight ^~Les east of t^e scath course of support any particular theory for the         the Annette -ad^o range, ano at an ele- cause of this accident Therefore, the         vation of 3,400 feet probable cause of accident remains            8  bo evidence vas fou^d of engj-e undetermined                                  malfunctioning or structural failure p^io1" to the time of the crash Findings                                      9  Annette Island Range was function- On the basis of all the available evi-        ing normally at the time of tre accidentdence 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-          Pro ba Me 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 thethe flight from Seattle at 1030, October      probable cause of thxs accident 26, 1947 3 The company forecast did not in-             BY THE CIVIL             AERONAUTICS clude information concerning the exces- sive turbulence which the flight experi-                   /s/ JOSFPh J 0rrGt . JR enced over Annette Island, though exces-                   /$/ OSWLD RrA\ sive turbulence could reasonably have                      Is! JOSH ZEE been forecasted from available weather                     /$/ HAROLD A JOJES data.                                                      /s/ RUSSFLL R ARA^S --- 16577 Supplemental DataInvestigation and Hearing                         last check over the route nnvolved, April The Civil Aeronautics Board was noti-             10, 1947 His last CAA physical examina- 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^ 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, 1947, and          physical examination was on October 10, September 29, 1948                                1947. Air Carrier                                       The flight engineer, Curtis L. Dun- woody, age 28 , held flight engineer cer- Pan American Airways, Inc., a New York            tificate 575026 His last CAA physical corporation with headquarters in 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 Aircraft the Civil Aeronautics Administration. Flight Personnel                                  NC 88920, a Douglas DC-4A aircraft, had been flown a total of approximately Captain A. N. Monsen, age 47, pos-                4,146 hours. sessed a valid airline transport pilot            The No. 1 engine had a total of 1,157 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 type airplanes. His last instrument               hours All had had 232 hours since check was taken March 10, 1947, and his           overhaul. ---16S77                                                                (I) II         Accident Investigation Report16577 SA- IM                                                                                                 File Mo. 1-0120CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORTAdopted: September 23, 19*19                                                             Released: Septeaber 26, 1969PAN AMERICAN AIRWAYS,            INC., HAVANA, CUBA---DECEMBER 0, 1048The Accident                                                              applied to the controls to take off. At approximately 1725,1 December 9,                                       The captain, sensing an unusual vlbratloi 1948,a Cortvair 240, NC-90666, owned by                                  at this time, took over control, closed . Pan American Airways, Inc., a scheduled                                   the throttles and applied the brakes. air carrier, and operated by Its Latin                                    Runway 5 on the Rancho Boyeros Airport Is ... American Division, crashed at Rancho                                      4,500 feet long and the aircraft had . Boyer os Airport, Havana, Cuba, during an                                 progressed down the runway about 2,600 attempted takeoff. The stewardess was                                     feet when the brakes were applied. The left outboard and the right Inboard tires slightly Injured; all of the other forty-                                 blew out within a short distance. As the three occupants were unhurt.                                              speed of the aircraft was still fairly ...History of the Flight                                                      high, the captain used, the emergency air brakes. However, the aircraft rolled Pan American Airways * Flight 428 was                                      off the end of the paved runway, con- the return portion of a trip originating                                   tinued 300 feet to the boundary of the at Miami, Florida, December 9, 1948, and                                   airport where It struck a ditch and scheduled to fly to.Bavana, Cuba, and                                      skidded to a stop 315 feet beyond the return. The crew consisted of Captain                                      airport .boundary. At the time of the Thuel V. Schuhart, First Officer Henry                                     accident, the weather was high overcast,, W. Brother ton, Purser Richard Abbott, and                                 visibility unlimited, celling unlimited, Stewardess Betty Jean Poe. The gross                                       wind EKE 6 miles per hour, temperature weight at the time of takeoff was 38,821                                   82 degrees Fahrenheit. pounds which was within the allowable limits and properly distributed. Taxi                                      Investigation clearance was obtained from the tower to                                   Investigation disclosed that the air- s Runway 5 with instructions to hold at                                      craft was extensively damaged.       . the intersection while another aircraft                                    The nose landing gear drag link bad was landing. On arrival at the inter-                                      failed, allowing the gear to fold rear-. - section the engines were run up and the                                    ward. As this occurred, the gear buckled . pre-flight check accomplished. At this                                     at the fork and moved slightly to the time when operating the right engine on                                    right, forcing the nose wheel to strike the right magneto there was fluctuation                                    the edge of the well and compressing the of 30 BEEP (Brake Mean Effective Pres-                                     fuselage upward. Failure of the left sure}., and the engine backfired several                                   main landing gear allowed It to fold di- times. The engine was operated at 30                                       rectly rearward. The right landing gear Inches of manifold pressure until the                                      was extended and locked. Examination of cylinder head temperature Increased from                                   the wain landing gear showed that the 130 to 200 degrees Centigrade, At this                                     left outboard tire and the right Inboard , temperature the magnetos were tested                                       tire had blown out. The left inboard again and the engines were, operating                                      tire showed little Indication of wear. within normal limits. When cleared for .                                   Both tires on the right side were dam- takeoff, the first officer, who was ;                                      aged by fire. seated oir the right hand side, started                                    : The left , wing was severly damaged In 5 : the -takeoff run.                                                        the vicinity of the broken landing gear^ : At an air speed of approximately                                         The trailing edge of the wing, the rear ; knots (109 nph>, back pressure<was                                        of the left engine nacelle and the left engine augment or tubes were bent upward .. : . TAll tinea referred to herein are East ora stand-'                    approximately 15 inches; the rear spar sM and based on the 24-hour clock...>;                                    was cracked. The outer section of the : ---16616                                                                                       JAccident iInvestigation Report   _ ---wing near the wing tip was badly damaged                                                                 Air brakes (for emergency use) are by sliding over the surface of the                                                                       standard equipment                 on the Coiivair 240 ground. Investigation disclosed that                                                                     The pilots had not received any trainingJ the right wing was severed just Inboard                                                                In their use other                 than written Instrue  .of tfce engine nacelle. It lay in an In-                                                              tlonsver tedpos It Ion and was held to the cen-                                                NC-90665 was equipped with Hamilton " ter section by means of control cables.                                                   Standard Propellers with the reversible Fire had substantially destroyed the                                                      feature made inoperative by the carrier; . right engine nacelle and a large portion                                                however, the aircraft was certificated <- of the leading edge of the right wing.                                                 by the CAA for operation by Pan American Examination of the electrical plug                                                        over this route without the use of the.jj ; whi'dh is attached to the flap selector                                                 reversible feature.valve disclosed a broken wire in the con-                                                 The runway, as previously stated, Is i trol circuit" for lowering the flaps and                                                4,500 feet long and the surface Is the plug Itself was partially out of its                                                  slightly irregular, described "as llkAa ; receptacle. The flaps were fully up,                                                      washboard.  Heavy marks were made by. ; which corresponded with the position of                                                 the left outboard wheel starting 2,600/ the flap control.                                                                         . feet from the southwest end of the run- The tip of a blade on the left pro-                                                                                                                                         2: way and they extended approximately . Speller was broken and the blades of both                                               feet; from this point to the end of .the propellers were bent rearward.                                                            runway were two narrow black lines. The .captain stated that during the                                                       Light marks, made by the left inboard ;J. takeoff run a vibration occurred causing                                                  wheel appeared adjacent to those of the him to reduce power and apply brakes.                                                     left outboard and continued to the end . . - In an effort to determine the source of                                                 of the runway. Heavy marks made by the L T vibratlpn, hydraulic units, pertinent                                                     right wheels appeared at a point 2,650" / parts of, the flap system, landing gear                                                   feet from the takeoff end of the: runway;: assemblies and brake units were shipped                                                   and continued for 250 feet. From this-> toMlamifofexamlnation. The left                                                           point and in line with the track-of the and there was                                                                             right inboard wheel two narrow. MaclcMi5'<? defective braking.                                                                        lines continued to the end of the runwAjir J-STests? of the right brakes were incon-                                                 Light marks made by the right outboard                                          J]pcjiisdve as they had been exposed to the                                                wheel appeared for the next 1,060 feet, X Sjflre which had destroyed the piston and                                                 followed by heavy marks to the end of j/ :cyJInder head seals.                                                                    the runway. Light marks, made by the/ < The left inb oar d and right outboard                                                   left inboard wheel together with heavy /brake linings were badly worn and pitted.                                                marks made by the right outboard wheely/? -; fhe linings of the other two brakes                                                    appeared on the ground beyond the runway: showed only moderate wear. The hydrau-                                                   and extended to the drainage ditch, a \ licsystem accumulator, the brake system                                                   distance of 300 feet. ;^yalves >and the flap hydraulic drive /rmotor were examined and functioned prop---                                            Analysis ;Lkt Havtoa, all hydraulic and air                                                        Though both the captain and the first '.T-lines in the; fuselage were capped and                                                officer sensed an unusual vibration dic- .                        of 4,000 pounds                                                  ing the takeoff run, the cause and nature/ P r'.rsgtiAre iheh hydraulic pressure; no                                              of the vibration was not learned. A J  malfunctioning was found. ; Another                                                     nosewheel shimmy or an unbalanced tire:  {i;0^iir\<w<s  test flown using the nose-                                               are among the possible causes of the vl^ wheel assembly of NC-00665, and also us-                                                  bration. However, during a testof' :i Ing miln landing gear tires which were ;                                                  another Convair, equlppedwlththeidefr- ?orn ih h sImilar manner to those found                                                   tlcal nosewheel assembly Including/:the/U? on the damaged aircraft. No vibration                                                     tires from the damaged aircraft andnsing occurred.                                                                                 tires on the main wheels similar iln :                  disclosed that <>n                                             no                  vibration occurred. December -8, 1848, all brake assemblies .                                                                     Although the right engine waa hea^djof this aircraft were Inspected and                                                       to backfire during the run-up period, checked. At this time assemblies with                                                     It                  was determined that this was new linings were liisialied on the two                                                   the cylinder bead temperature ,belng^t0j^ left wheelsr and theinboard wheel.                                                       low prescribed limits. When .noraai^'B^-M * 1S616 From PilotM'anuals/com /"RareAviation^zom-?    =. - r : v. - <      - Accident I Invest!gat ion Report                                                         3 operating temperature was reached, the       | In 1947 and 1948, accelerate stop engine functioned properly. This Is sub-   tests were conducted by the CAA on the stantiated by both the captain and the       Convalr 240 as a part of its type cer- first officer.                               tification tests. These tests were con- After the accident the flaps were            ducted with gross weights between 33,160 found fully retracted with the actuating     pounds and 39,500 pounds (the subject switch in neutral. However, the crew         aircraft grossed 38,821 pounds) and at  stated that prior to takeoff, the flaps    speeds up to 117 knots. All tests were were lowered and they did not remember       conducted without reversing the propel- raising them. They may have been raised      lers and with 24 degrees of flap. The unconsciously since the training pro-        test data indicate that with a weight of  cedure for this aircraft includes the rd-  38,900 pounds and a speed equal to 95 .traction of flaps when brakes are ap-       knots, the aircraft could have been plied. The electrical cannon plug to         stopped in a distance of lr552 feet with . the flap motor control valve had a broken    the use of the brakes only. From a sum- . wire and was partially out of Its recep-     mary of all the tests. It Is concluded tacle. Scratches indicated that it had       that this stopping distance would be been loose for sometime. Had the wire        somewhat increased by the blowing out of been broken prior to the accident the        a tire on each side. It must be realized, .flaps could not have been lowered.          that these figures were obtained under As previously stated two tires blew          test conditions of uniform tires, uni- ; ..out within a short distance after the      form brakes and no pilot apprehension as . brakes were first applied. Although          to sufficient runway remaining in which thei*e was evidence of braking action        to stop. throughout the entire run, the aircraft      Evaluating all the evidence from the was .not greatly retarded. At an approx-     investigation of this accident, together imate speed of 95 knots (109 miles per       with facts observed through day-by-day hour), the aircraft was nearly airborne      scheduled operation, Pan American Air- with most of its weight off the wheels.      ways, Inc. , concluded that "the braking - Under these circumstances it would have      system of the Convalr 240 aircraft is. been easily possible to lock the wheels,     critical under certain operating condl-4; K*i causing the tires to skid sufficiently       tlons." As a result, the company instl*^; to blow out; All but the left inboard        tuted the following: : (a) PropelLer re-* tire indicated a skidding action at some     versing was changed from a regular modi- time during the run as evidenced by          flcatlon to an immediate campaign modi* ?/ marks on the runway and this tire showed     flcatlon; (b) high capacity brakes, moderate braking action throughout.          under test at time of accident (although.': Even though air was applied to the brakes    not Installed in NC-90665>, are now in- J? during the emergency, the aircraft failed    stalled in the companys CV-240 air- to stop. However, the fact that most of      craft. These high capacity brakes re- the run was completed with only two          tain their . braking effectiveness some* wheels capable of producing normal brak-     what better under increased heat and . ing action may have contributed to the       therefore have a higher degree of effi-  failure of the brakes to stop the air-       clency than the brakes Installed at the . draft within the required distance.. The     time of the accident; (c) the pilot '  brake linings of the left inboard and the    training curriculum was enlarged to in--- ; right outboard wheels were badly worn and  elude checking each pilot in the actual *; 'pitted, indicating that they had been       use of the air brakes.  subjected to Intense frictional heat.        A thorough examination of the company /These were the two wheels whose tires did   maintenance records revealed that main- not blow out. The additional weight          tenance of NC-90665 was satisfactory. . : placed on these wheels, together with the    The weather was not a contributing attendant increased tire friction, pre-      factor. vented them from further skidding. Also,        the heavy application of the brakes could  Findings; ?have. caused them to overheat and thus      1. The carrier, the 'aircraft, and the .'become 1 ess effective.                    crew were properly certificated. Accident Investigation Report2. The initial airworthiness certifi-           7* The aircraft maintenance records cation of the aircraft did not require          indicated that the brakes were Inspected the incorporation of the reversible pro-        on December 8, 1948, and that new brake peller feature, and the carrier elected         linings were installed on both left - to operate the alrcraft without such fea-        ~ - wheels and the right inboard wheel of : ture since the certification tests indi-        the main landing gear assembly. cated the aircraft could be stopped by          8. Investigation disclosed no evi- the use of the wheel brakes only*               dence as to the cause or nature of the 3. The crew sensed an unusual vibra-            unusual vibration. tion during the takeoff run at an ap- proximate speed of 95 knots, immediately        Probabie Cause * asthrottled the engines and applied               The Board determines that the prob- brakes*                                         able cause of this accident was inabil- 4. The left outboard and the right              ity to stop the aircraft under marginal inboard tires blew out within 550 and           conditions: of stopping distance because 250 feet of travel respectively, after          of inadequate braking effectiveness-* : the brakes were applied. 5. The aircraft failed to stop within                   BT THE CIVIL               AERONAUTICS BOARI the required distance because of inade- quate braking effectiveness.                                             /si       JOSEPH J. 0 'CORNELL, JR. .   6. A test flight of a similar air-                                             OSWALD RYAtf plane using the nose wheel and tire as sera-                                       JOSH LEE biles of NC-90665 did not reveal any                                     /s/       HAROLD A. JONES unusual vibration.                                                                 RUSSELL B. ADAHS --- walet- Supplemental DataInvestigation and Hearing                    flying hours, of which 387 were in Con- The Civil Aeronautics Board was noti-        vair 240 type equipment. His last CAAfied at 1815, December 9, 1948. An in-       physical examination was passed June 25, vestigation was begun immediately in ac-     1948. First Officer Henry W. Brotherton cordance with the provisions of Section      age 27, possessed a valid airman certif- 702 (a) (2) of the Civil Aeronautics Act     icate with a commercial pilot and instru of 1938, as amended. A public hearing        inent rating. He had logged a total of was ordered by the Board and held in Coral   2,616 flying hours, of which 6 hours were Gables, Florida, February 15 and 16, 1949.   In Convalr 240 type equipment. His last CAA physical examination was on August Air Carrier                                  30, 1948, The other two members of the Pan American Airways, Inc., a New            crew were the purser, Richard Abbott; York corporation with headquarters in New    and the stewardess, Betty Jean Poe. York City, is a holder of a certificate      The Aircraft of public convenience and necessity          NC-90665, a Consolidated Vultee issued by the Civil Aeronautics Board and    CV-240 aircraft, had flown a total of an air carrier operating certificate         approximately 392:44 hours It was cur- issued by the Civil Aeronautics Adminis-     rently certificated by the CAA. tration.                                     The aircraft was equipped with two Flight Personnel                             Pratt & Whitney R2800CA-18 engines and with Hamilton Standard Hydroroatlc pro- Captain Thuel V. Schuhart, age 29,           pellers. No. 1 engine had a total of possessed a valid airline transport rat-     393:29 hours, and No. 2 engine a total ing and had logged a total of 4,210          of 197:27 hours. ---15616                                                                           (I) CI V E L AERONAUT!CS BOARDACCIDENT INVESTIGATION REPORTAdopted: August 10, 1948                                                                                                            Released: August 11, 1948PAN AMERICAN Al RWAVS---ACCRA, GOLD COAST, AFRICA---MARCH 24                                                                  1948A Lockheed Constellation of Jnxted                                                               with the exception that the gear exten- States registry, NC 88833, made a suc-                                                           sions appeared to be a little slower than cessful wheels-up landing at Accra, Gold                                                         usual which fact was attributed to the Coast, Africa, March 24, 1948, at 1520                                                           low pressure, low capacity auxiliary unit GMT.151 The aircraft had departed La-                                                            being used. On the basis of these satis- Guardia Field, New York City, New York,                                                          factory operational tests the aircraft as Pan American Flight No. 150 at 1356,                                                          was cleared for flight to Accra. March 22, 1948, bound for Jonannesburg,                                                          The flight departed Dakar at 0615, Union of South Africa, with scheduled                                                            rfarch 24, arriving over Accra the same stops at Santa Maria, Azores , Listen,                                                           da, at 1135, at which time the nose whet 1 Portugal, Dakar, Senegal, Accra, Gold                                                            rgain failed to extend to the lock-down Coast; and Leopoldville, Belgian Congo.                                                          position. After the next Three hours o'* The flight departed Santa Maria at                                                               so had been spent m the vicinity of the 2342, March 22, under tne command of Cap-                                                  4     airport in unsuccessful attempts to ex- tain A. L. McCullougn, following a rou-                                                    *1    tend the gear, Captain McCullough elected i tine flight from New York. On arrival at                                                   i     to make a wneels-up landing. Necessary 1 Lisbon difficulty was experienced m ex-                                                     A    preparations for such an under taxing we-e 1 tending the nose wheel gear co the lock-                                                         made and at 1520 a landing was effected down position. This difficulty, how-                                                             on a laterite strip alongside the runway ever, was overcome by applying a few                                                             titnout injury to passengers or crew or strokes to the emergency extension handle                                                        extensive damage to the aircraft* and a landing was made at 0340, March 23.                                                  J     After the aircraft was raised it was The aircraft was inspected, and serv-                                                            found that the extension of the rose iced, and departed Lisbon for Dakar at                                                           wheel gear was being restricted bj tne n     hydraulic actuating cylinder, the piston 0815, March 23. On arriving at Dakar the nose wheel again failed to extend to the                                                         of which did not extend sufficiently tolock-down position in a normal manner.                                                           permit the engagement of the lock-down It was, however, again successfully ex-                                                          uevice. This actuating cylinder, serial tended by the operation of the manual                                                            $255, was removed and replaced by a new emergency extension handle, and the Dakar                                                        one from stock. Following this install i- landing tfas accomplished at 1545, March                                                         1-jon the nose wheel functioned normally 23. Because of the difficulty encoun-                                                            as did all hydraulic units m the lar.aiig tered with extension of the nose wheel                                                           gear system. Upon disassembly of the de- both at Lisbon and Dakar, Captain                                                                fective cylinder it became evident that McCullough called for a thorough inspec-                                                         the piston had not been machined m ac- tion of the unit before proceeding fur-                                                          cordance with the manufacturers speci- ther. This necessitated a delay in                                                               fications and drawing $405371, which schedule.                                                                                        calls for a 1/16" 45 chamfer around tn3 The aircraft was jacked up and several                                                           periphery of the piston ends on both the nose wheel operational tests were con-                                                           retract and extend sides. ducted using both emergency extension and                                                        The fact that this 1/16" chamfer had normal system pressures. The system                                                              not been made resulted in the piston end pressure was obtained by the use of an                                                           becoming peened to a slightly larger di- outside auxiliary hydraulic pressure                                                             ameter on the retract side due to its re- unit. All of these tests were normal                                                             peated bottoming on the cylinder end and this in turn resulted in the scoring of both piston and cylinder. The damaged * All times referred to herein are Greenwich Mean and                                            surfaces of both piston and cylinder and based on the 24-hour clock. --- 19842                                                                                        (1) zthe accumulation of metal chips eventu-     of this accident was failure of the now ally limited the full extension of the      wheel actuating mechanism which necessi- nose wheel actuating mechanism.             tated a landing with the wheels Maintenance records of the aircraft         retracted. indicated that the cylinder removed had              BY THE CIVIL AERONAUTICS BOARD: been installed new on September 18, 1947, and that it had operated satisfactorily     /s/ JOSEPH J. OfCOWELL, JL throughout the 1,165 hours the aircraft had flown between that date and its ar-     /s/ JOSH LEE rival over Lisbon on March 23.              Is/ HAROLD A. JONES Probable Cause                              I si RUSSELL B. ADAMS Upon the basis of available evidence        Ryan, Vice Chairman, did not partic- the Board finds that the probable cause     ipate. --- 19842 File Ko. 6-0034 SA-169CIVIL AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: June 23, 1948                                                                                                                     Released" June 24, 1948PAN AMERICAN AIRWAYS, INC., ---SHANNON, EIRE, ---APRIL 55, 19^8The Accident                                                                                                    A faulty rheostat switcn was found to A Pan American Airways Lockheed Con-                                                                           be the cause of the fluorescent lightstellation, aircraft NC-88858, Flight 1-                                                                        failure, but since a spare switch could 10, en route from London., England, to                                                                          not be located, it was not changed at Shannon, Eire, crashed near the Shannon                                                                         London. An entry describing the defect Airport at 0234,1 April 15, 1948. Twenty                                                                        was placed m the aircrafts Form C, the passengers, including one infant, and 10                                                                        airplane flight log, and the captain and crew members were fatally injured. One                                                                          the flight engineer of the new crew were passenger escaped with minor injuries..                                                                         informed by the companys maintenance The aircraft was totally destroyed by im-                                                                       supervisor of the condition. Though no pact and fire.                                                                                                  actual maintenance was accomplished, the lights again appeared to be operating History of the Fl ight                                                                                          normally, so the captain, F. C. Jakel, decided to take-off, departing from Lon- Pan Americans Flight 1-10, originat-                                                                           don at 0035, April 15, 1948, for Shan- ing in San Francisco, California, April                                                                         non. At this time available weather 10, 1948, was scheduled to fly around the                                                                       forecasts indicated that at the esti- world to New York, New York. In accord-                                                                         mated time of the flights arrival at ance with company practice the flight                                                                           Snannon the ceiling there would be 700 changed to a different aircraft, NC-                                                                            feet with a higher cloud layer at 1,000 88858, at the Pan American Airways base                                                                        feet, and visibility 4 miles. in Calcutta, India. The flight took off                                                                         At 0159, April 15, 1948, the flignt from Calcutta, April 13, 1948, and con-                                                                         reported being at an altitude of 4,500 tinued without incident via Damascus,                                                                           feet, contact, over the Limerick Junc- Syria, and Istanbul                                                               ? Turkey, to Brussels         tion fan marker, located 25 statute Belgium. During a                                                                 night landing ap-             miles southeast from the Shannon Air- proach at Brussels                                                                the fluorescent light         port, and requested permission to make a ing on the left or                                                                pilot side of the             practice approach to the field with the cockpit went out.                                                                 Since the only other          use of the instrument landing system. lighting immediately available was a                                                                            Shannon Tower cleared the flight for chart light which was focused on tne au-                                                                        this approach. The tower advised that 3 tomatic direction finder indicator, the                                                                         hours previously the instrument landing flight instruments could not be read, and                                                                       system equipment on the airport had been the remainder of the landing approach was                                                                       reported faulty, but that it had since accomplished without visual reference to                                                                        been serviced and was operating normally the flight instruments.                                                                                         according to its monitoring board, An examination was made of the fluo-                                                                            though not flight-checked. rescent lights after the landing. They                                                                          At 0210, the flight reported that it appeared to operate normally, so the                                                                            was proceeding to the outer marker, 5.2 flight departed from Brussels, continu-                                                                         statute miles northeast of the Shannon ing without difficulty until on the final                                                                       Airport, and also made a report, routine landing approach into London. When the                                                                          for Pan American flights, "mechanical power was reduced tne same pilots fluo-                                                                        condition okay." In response Shannon rescent lights again went out. This time                                                                        Tower advised the flight that the the chart light was focused on the air-                                                                         weather over tne field was "fog speed indicatoro The approach was con-                                                                          patches, 3 miles visibility, cloud base tinued, and the landing was accomplished                                                                        400 feet, sky 6/10 covered, wind from without Incident.                                                                                               325 degrees at 4 miles per hour." The LA11 times noted in this report are Greenwich Me-                                                               flight was instructed to land on runway ridian and based on the 34-hour cxOck.                                                                          23, the runway for which the instrument*19393 From PilotManuals.com / RareAviation.com 2                                                      Accident Investigation Report landing system was projected. It was                   appeared too high to him for the land-also requested to report when making the               ing, and he heard power being applied to 180 degree procedure turn for the in-                  the engines for the pull up. bound instrument approach to the field,                According to this passenger, the en- and when over the outer marker. The re-                gines seemed to be operating normally quested position reports were not re-                  also during the second approach. The ceived by the tower, but at 0220 the                   "fasten seat belt ---no smoking" sign was flight did report a missed approach,2               on. He heard the flaps extend, and ob- and advised that it was going around for               served that the flight attitude was nor- a second approach. At this time the                    mal. He stated that the first contact with flight was observed through a break m                  the ground felt as though the airplane the clouds by the Shannon Tower, which                 had made a hard landing on the runway. was the first time that the aircraft had               Immediately following, however, severe been seen in the vicinity of the Shannon               jolts were felt, and flames swept Airport. The aircraft was reported as                  through the cabin from the forward part 500 feet above the ground, over, and m                 of the fuselage. He then realized that line with runway 23* Power was heard                   the airplane had crashed. He had been being increased, and the aircraft was                  thrown forward in his seat but was saved observed turning left.                                 from injury by his safety belt. When On the second approach, at 0227, the                   the aircraft stopped, he noticed that flight reported making its 180 degree                  though filled with flames the cabin re- procedure turn and was cleared for land-               mained substantially undamaged, and that ing by the tower. One minute later,                    all passengers were in their seats, but weather conditions at the field were                   made no sound or movement. He said that transmitted to the flight as "fog                      he did not believe himself physically or patches, visibility 2 1/2 miles, 6/10                  mentally capable of opening any of the cloud base 400 feet, 4/10 cloud base 300               emergency exits, so he crawled toward feet^ wind 325 degrees, 3 miles per                    the rear of the cabin, and dropped hour, altimeter 30.29." The flight re-                 through a large tear in the fuselage to ported approaching the outer marker at                 the ground. 0231 at which time the tower advised                   Investigation that another flight which had just taken off had reported a ceiling of 500 feet                 The aircraft first struck a stone when northwest of the field. Flight                    fence, which collapsed the nose and left 1-10 acknowledged this information,                    main landing gear, and tore the right which was the last communication re-                   main landing gear from its mounting. ceived The aircraft was not observed                   All four engines were also torn from the at any time during the second approach ?               aircraft during the course of the crash, until a^ter it struck the ground.                      and came to rest slightly forward of the The aircraft struck the ground 2,380                   main wreckage which was 1,780 feet feet northeast of the approach end of                  northeast of the end of runway 23* The runway 23, and directly in line with                   empennage, broken into three sections, that runway. Flames followed immedi-                   was scattered around the fuselage and ately after impact, and consumed a great               wings portion of the wreckage.                               Marks on the ground made by the pro- The sole survivor, a representative                    pellers indicated that at impact all had of the Lockheed Aircraft Service, Inc.,                been rotating with normal glide power. seated m the cabin at a location                       The governor for the No. 1 propeller was slightly behind the trailing edge of the               bench-checked and found to be set at right wing, stated that on the first ap-               2300 revolutions per minute. The dis- proach all engines seemed to be operat-                tance between the individual blade marks ing normally, and no unusual maneuvering               for propellers Nos. 1, 2, and 3 were all of the aircraft was experienced. He                    about 38 inches apart. Forward speed of stated that he did not observe the run-                the aircraft was calculated to be ap- way lights and other field lighting un-                proximately 108 miles per hour. Since til the aircraft was directly over the                 considerable deceleration probably oc- field. The altitude of the aircraft                    curred before the propeller blades marked the ground, the speed of the air- /J This phrase Is used in all cases when the pilot        craft on final approach before first im- wishes to advise the tower that the alrc^alt will not  pact was substantially greater. land hut will circle for a second landing approach All evidence found and the statement                                     course offered for familiarization with of the surviving passenger indicated                                     the instrument landing system. Thisthat all engines were operating normally                                 course included 2 hours of Link trainer during the approach An examination of                                    time, and 4 hours of actual practice in the cockpit controls and instruments was                                 an airplane. Captain Jakel after the impossible because of complete fire de-                                  completion of this training was also struction. however, no indication was                                    given refresher training. He was con- found that other than normal operation                                   sidered a competent pilot by the company, was experienced before the crash. Like-                                  and was familiar with the airport and wise, the almost complete destruction of                                 surrounding area at Shannon, Eire. the airborne radio equipment made it im-                                 A synoptic surface weather chart pre- possible to determine its operational                                    pared m the London Meteorologicalstatus prior to the accident, but all                                    Office, at 2100, Auril 14, 1948, showed communications between the flight and                                    that a high-pressure area extended the tower were made without any diffi-                                   northeasterly from               the Azores covering culty.                                                                   the route flown by               Flight 1-10. This A complete examination of the records                                   high-pressure area               resulted in a westerly of Shannon Airport revealed that the ra-                                flow of relatively               warm moist maritime dio range and instrument landing system                                 air over the land area in the vicinity equipment were operating normally at the                                of Shannon. A weak warm front was rep- time of the accident. A ground and                                      resented on the same chart, extending flight check of ail the instrument land-                                from Iceland southeasterly through Eire. ing system equipment was accomplished                                   No adverse               weather was associated with after the crash, which included checking                                this front               m Eire, and at the time of the localizer and glide path, the outer,                                the flight it had become practically middle, and inner markers, and the com-                                 stationary pass locators. The operation of the com-                                At the time of take-off from London plete system was found normal. Various                                  good flying conditions existed over the types of failures were simulated, and                                   entire route. Strato-cumulus clouds the monitoring equipment was found to                                   with bases at approximately 4,300 feet give adequate indication of malfunction-                                were formed over the London area,                    At ing within the 70 second cycle                     which was            this time Shannon was reporting                      "ceil- required for one complete scan                     of the               ing and visibility unlimited, and wind from alarm circuita                                                          270 degrees at 3 miles per hour." Fore- The ground control approach                            (GCA)             casts available to the flight prior to equipment at Shannon Airport was not op-                                 its departure indicated that generally erating at the time of the accident.                                     clear weather would be encountered forShannon Airport, however, is completely                                  approximately the first two-thirds of equipped with tne necessary radar equip-                                 the trip, then layers of broken clouds ment for ground control approachAt                                       These same forecasts indicated that at the time of tne accident this equipment                                  the time of the flights arrival, Shan- was being used only during hours of day-                                 non would be covered by a layer of oro- light to train ground personnel.                                         ken stratus clouds at approximately 700 Runway 23 at Shannon Airport, for                                        feet, and that visibility would be 4 which the instrument landing system was                                  miles. Prestwick, Scotland, the alter- projected, is 7,000 feet long and 220                                    nate, was predicted to have ceilings at feet wide. Though the Bartow lights on                                   1,200 feet, visibility of 15 miles, and the runway were on at the time of the                                    occasional light rain. A new terminal accident, the installation of Bartow ap-                                 forecast for the Shannon Airport re- proach lights to the runway had not been                                 ceived in London, at 2222, predicted completed and were not operating. Ter-                                   that the cloud base would become as low rain northeast of runway 23 consists of                                  as 300 feet during the night hours of low rocky hills, covered with brush,                                     April 14, 1948* This new forecast was trees, and stone fences . Elevation at                                   not received by the flight in London, the point of impact was 12 feet above                                    but was delivered to Pan American Air- runway 23.                                                               ways at Shannon. Captain F. C. Jakel had logged a                                         Conditions actually encountered by total of 6,230 flying hours, of which                                    the flight en route were substantially 1,564 were m Constellations. He had                                      the same as those forecasted, except completed the Pan American training                                      that ceiling and visibility were --- 19398 From PilotManuals.com / RareAviation.com considerably lower than had been indi-    components of the instrument landing cated to the flight by the forecast fur-  system, the localizer, the outer, mid- nJshed at London. When the flight ap-     dle, and inner markers, and the compass proached the Shannon Airport, fog         ; locators, were all found to operate nor- patches had formed, visibility was re-    mally when examined and flight-checked duced to 3 miles, and there were layers   after the accident. Therefore, the pos- of broken clouds, with a ceiling of 400   sibility that the airplane struck the feet The wind was from 325 degrees at     ground as a result of maloperation of 4 miles per hour.                         the ground installation for the instru- At 0228, one minute after Flight 1-10     ment landing system also seems to be ex- had reported making its 180 degree pro-   tremely remote. cedure turn for its second approach to    An erroneous reading of an altimeter, the Shannon Airport, visibility was re-   of the instrument landing system indi- ported as reduced to 2 1/2 miles, and a   cator (ILS), or of any of the flight in- layer of broken clouds was reported with  struments could have misled the pilot a ceiling of 400 feet with scattered      during his execution of the second ap- clouds below at 300 feet. Fog patches     proach. This possibility cannot be were also reported, however, as men-      totally eliminated, since the flight in- tioned above, another flight that de-     struments were destroyed by fire, how- parted from Shannon at approximately      ever, an Instrument approach is not made this time reported the ceiling northwest  by reference to any one Instrument. , of tne field to be 500 feet.              Furthermore, one purpose in specifying a Discussion                                minimum approach altitude is to provide for a margin of safety to compensate for In view of the surviving passengers      possible errors in flight instruments. testimony, It appears highly improbable   In view of the fact that this flight ex- that any mechanical difficulty, other     ecuted one practice approach without re- than the possible failure of the pilots  porting difficulty, it appears very un- fluorescent lights, occurred in the op-   likely that any substantial maloperation eration of the aircraft prior to the      of the flight instruments existed. Cer- time of impact. The survivor was very     tainly there was adequate opportunity familiar with the airplane, and observed  for cross reference and comparison of no abnormal maneuvers or sounds which     the readings of all the flight instru- would have indicated trouble with either  ments before initiating the second ap- the engines or the aircraft. Further-     proach . more, tne flight, before initiating its   It was impossible at the scene of the first approach, reported "mechanical      accident to determine who occupied the condition okay", and the crew at no time  pilot's seat. It may have been the after this report indicated in any man-   first officer who had Just previously to ner that mechanical trouble was being     this flight unsuccessfully flown a stand- experienced Also, no evidence was found   ard radio 'ange approach into the Shan- during the course of the investigation    non Airport. Nevertheless, the captain which indicated any mechanical malfunc-   : was responsible for the safe operation tioning or structural failure.            of the aircraft, and it is to be pre- The possibility of a defect in the        I sumed that he would have fulfilled his operation of the instrument landing sys-  duty by assuming control of the air- tem at the Shannon Airport was thor-      plane. though he may have been in the oughly investigated, since a distortion   co-pilot's seat, had he become aware of of tne glide path might contribute to an  any hazardous condition of flight. aircraft making an approach too low to    The only explanation of this accident clear the ground. The instrument land-    that appears reasonable, considering all ing system was found to be operating      known circumstances, is that the air- normally -when flight checked. Further-   craft was flown too low in the approach more, no deviation had been observed on   for landing. It is apparent that the the instrument landing system monitoring  airplane would not have struck the board Immediately before the landing ap-  ground short of the runway had the proaches made by Flight 1-10, and the     flight been able to establish clear vis- monitoring system was found to give a     ual reference to the field, or had the true indication of any material devi-     flight not descended below the minimum ation of the glide path. Other            approach altitude of 415 feet in the See our selection of aviatioon documents at RareAviation.com Accident Investigation Reportexecution of its second instrument ap-                                                            fluorescent light before Captain Jakel proach. Accordingly, it must be con-                                                              established visual reference to the run- cluded that the airplane was flown below                                                          way when at or above the minimum ap- the minimum approach altitude when no- clear                                                      proach altitude of 415 feet, there should visual reference to the field existed.                                                            have been sufficient time and altitude No reliable evidence was obtained                                                                to place a flasnlight into use, or to during the course of the investigation to                                                        focus the overhead chart light on the conclusively determine ceiling and visi-                                                         pilots instrument panel. In fact, he bility conditions over the approach area                                                         could have adjusted himself to watching to runway 23. The weather conditions                                                             the instruments on the right instead of that existed m the vicinity at that                                                              the left side of the instrument panel. time, however                                                were conducive to the               However, had the pilots fluorescent formation                                    of fcg and low stratus clouds,                      light failed when there was no or only and it is                                    hignly probable that low                            intermittent visual reference to the layers of                                    stratus clouds were formed                          runway, and had the aircraft been flown verv near                                    the ground between tne outer                        close to the ground without clear visual marker and the end of runway 23                                                      In           reference, the pilot might have been of the fact that the surviving pas-                                                              left without immediate means of flight senger stated that he was able to see                                                            orientation at a time when a small lossthe airport lights when tne airplane                                                             of altitude would result in a crash. first passed over the airport, at which                                                          Therefore, a failure of the fluorescent time it was at an estimated altitude of                                                          light might have contributed to this ac- 500 feet, and that the ceiling was re-                                                           cident, but could not be, in itself, the ported northwest of the                                               field to be 500            cause. feet by another flight,                                               ceiling and vls-ibility conditions over                                               and to the west             Findings of the airport may have                                               been consldera-             On the basis of all available evi bly better than they were over the area                                                            dence, the Board finds that northeast of the field from which tne                                                              1  The                 aircraft, the carrier, and the landing approaches were made. There-                                                               crew were               properly certificated, fore, the pilot in his execution of the                                                            2. The                  aircraft, at                the time of its second approach may have felt confident                                                            departure               from London, England                      to Shan that he would establish clear visual                                                               non, Eire,                had a known defective fluo- reference..to the field m ample time to                                                            rescent light which illuminated the safely execute a landing, and so contin-                                                           pilots instrument panel. ued below the minimum approach altitude                                                            3. The flight departed from London, while still in instrument weather.                                                                 at 0035, April 15, 1948, when available Had the aircraft been flown "on in-                                                                weather information at London indicated struments" below the minimum approach                                                              that a night instrument approach would altitude, and bad the pilot1 s fluores-                                                            be required for the landing at Shannon. cent lights then failed, the captain                                                               4. Weather conditions encountered en would. have been in the highly critical                                                            route were substantially as forecasted situation of being close to the ground                                                             though ceiling and visibility conditions without any means of flight orientation.                                                           over the Shannon Airport were lower than On the other hand, had the fluorescent                                                             had been expected. At the time of the lights failed prior to the time that the                                                           flights instrument approach, a ceiling flight reached its minimum approach al-                                                            of 400 feet was reported over the                                   Shan- titude, there should have been suffi-                                                              non Airport with scattered clouds                                   under cient time and altitude to allow the                                                               neath, visibility was reported to                                   be captain and co-pilot to accommodate                                                                2 1/2 miles, with fog patches. themselves to the emergency.                                                                       5. Except for the possible failure of If the pilot had had unobstructed                                                                  tne defective fluorescent light de- visual reference to the runway, failure                                                            scribed above, there is no evidence toof the fluorescent light on his side of                                                            indicate that any mechanical difficulty the cockpit would not in itself account                                                            was experienced in the operation of the for any particular difficulty in his                                                               aircraft before the time of impact. completion of the landing approach.                                                                6. The instrument landing system at Airspeeds and altitudes could have been                                                            Shannon and all navigational radio aids called out by the co-pilot. If there                                                               in the vicinity of the Shannon Airport had been a failure of the pilots                                                                  were operating normally at the time of the accident. The aircraft made a prac-   continuation of an Instrument approach tice approach, using the instrument       to an altitude insufficient to clear the landing system, flew over the field at    terrain. approximately 500 feet, and proceeded in  A contributing factor may have been the accomplishment of its second and at-  the failure of the pilots Instrument tempted final approach without reporting  fluorescent light. any difficulty. 7. The aircraft, while executing a        BY THE CIVIL AERONAUTICS BOARD second Instrument approach, using the instrument landing system, struck the     fsj JOSEPH J. 01 CON NELL, Ji ground 2,380 feet from the approach end of the intended runway, and was immedi-   / st OSWALD RYAN ately enveloped In flames.                /$/ JOSH LEE Probable Cause                            /s/ HAROLD A. JONES The Board determines that the proba-      Adams, Member, did not participate. ble cause of this accident was the --- 19398 Supplemental DataInvestigation and Bear in                                                             He was employed by the company December The Civil Aeronautics Board was noti-                                                 23, 1942, and had logged a total offied of the accident shortly after mid-                                               3,310 flying hours, of which 956 were in night on April 15, 1948. by CAA communi-                                              Constellations. He had successfully cations at I^aGuardia Field, New York.                                                passed an instrument check December 22, 1947. However, just previous to this An investigation was immediately initi-                                               flight he had unsuccess fully flown an j ated In accordance with the provisions                                                Instrument approach into the Shannon Air- ; of Section 702 (a) (2) of the Civil Aero- nautics Act of 1938, as amended. Two                                                  port. His last CAA physical exawlnation Air Safety Investigators departed from                                                was accomplished February 25, 1948. The co-pilot-navigator, E. G. Wallace, age New York, New York, April 16, 1948, for                                               28, possessed- a commercial pilot rating. Shannon, Eire, and assisted in an inves-                                              He was employed by the company June 25, , A tigation conducted by a representative                                                1945. At the time of the accident he of the Irish government. A public hear-                                               had logged 2,288 flying hours, of which bJ ing was ordered by the Board and was                                                  1,361 were in Constellations. His last  held in New York, New York, May 13, 1948 CAA physical examination was accom-         plished May 23, 1947. His last instru- J Ai r Carrier                                                                          Trent check was accomplished November 22,Pan American Airways, Inc., a New                                                     1947. Third Officer H. R. LeBlanc, age York corporation with headquarters in                                                 29, possessed a commercial pilot rating. . New York City, Is a holder of a certif-                                               He was employed by the company October icate of public convenience and neces-                                                30, 1946. He had a total of 3,566 fly- sity awarded by the Civil Aeronautics                                                 ing hours, of which 1,020 were in Con-. Board, which authorizes the company to                                                stellatlons. His last CAA physical ex- conduct flight operatJons between New                                                 amination was accomplished August 19, York, New York, and Calcutta, India.                                                  1947. His last instrument check was ac- \< Service under this certificate has been                                               conrplished January 9, 1948.                v?' conducted through the Shannon Airport, Shannon, Eire, since October 20, 1945,                                                The Aircraft under an air carrier operating certif-                                                  NC-88858, was a Lockheed Constella- icate issued by the Civil                                Aeronautics                  tion, Model 49. It had a total of 3,861 J Administration.                                                                       flying hours, 2,407 of which had been accumulated since overhaul- The lastFl i aht Personnel                                                                    *                                                                                                                                                                    < *  I Or                                                                                    inspection was accomplished April 9,Captain F. C. Jakel, age                                    35, possessed          >  1948. This aircraft had installed four.a valid airline transport                                   pilot rating.             745C18BA3 engines. He was employed by Pan American Airways                                               The No. 1 engine had a total of 2,491 May 5, 15)41, and at                          the time of the ac~                           hours, and 666 since the time of over-      cident had logged a                           total of 6,230 fly-                           haul. The No. 2 engine had a total of     ' ing hours, of which                           1,564 were obtained .                         1,739 hours, and 247 since overhaul. in C ons te11a 11ons .                        His last Instrument                           The No. 3 engine had a total of 2,149 check was accomplished October 10                                            1947,          hours, and 667 since overhaul. The No. . -                                                                                        J*                                                                                                                            .                                           .                                                                                                and his last route check April 5,                                   1948.             4 engine had a total of 2,627 hours, and He successfully passed a CAA physical                                                 643 since last overhaul- examination March 9, 1948. First Of-                                                  The aircraft was equipped with Ham- ficer C. M. Henson, age 27, possessed                                        a        ilton Standard propellers, .Model          y valid airline transport pilot rating.                                                 33S-6O-79, ---15396From RilotManuals.com / RareAviati6n.com SA-188                                                                                       File Ko. 1-0013ACCIDENT INVESTIGATION REPORTCIVIL AERONAUTICS BOARDAdopted: October 10, 1949                                                       Released: October II, 1949PAN AMERICAN AIRWAYS, INC. AND CESSNA lUO--- PORT WASHINGTON. LONG ISLAND. NEW YORK. JANUARY 30, 1949The Accident                                                    they Intended to fly to New York and re- Pan American Airways Flight 100, a                             turn non-stop.Between 1620 and 1622 both aircraft Lockheed Constellation, aircraft N086530,                       approached Port Washington, ten miles and a Cessna 140, aircraft NC-76891,                            east of LaGuardia Field on Red Airway collided over Port Washington, Long                             23. The Constellation climbing en route Island, N. Y., at 1622,* January 30,                            at an indicated air speed of 175 miles 1949. The pilot and passenger In the                            per hour, was being held on an easterly Cessna were killed, and the aircraft was                        heading of 95 degrees. It had taken off totally destroyed. None of 23 passen-                           from Runway 31 at LaGuardia, after which gers or crew of 10 in the Constellation                         the flight had turned right onto the was injured, but the aircraft was sub-                          first indicated course. Captain Knuth stantially damaged.                                             flew while Copilot Wade accomplished History of the Flight                                           necessary cockpit checks and radio con- tacts. The Cessna, cruising at an esti- Pan American Airways Flight 100 de-                            mated 108. miles per hour and at an alti- parted from LaGuardia Field, New York,,                         tude of 3,500 feet was flying the return N. T., at 1616, January 30, 1949. Captain                       course to Meriden of approximately 40 George F. Knuth flew as pilot, and First                        degrees. Officer Malcolm S. Wade flew as copilot.                        Visibility conditions were good, the The aircraft carried 23 passengers, the                         only restriction at 3,500 feet being a crew of 10, a fuel load of 4,700 gallons,                       layer of light haze which reduced hori- and 1,426 pounds of baggage and cargo.                          zontal visibility to about five miles. Total aircraft weight at time of takeoff                        The sun, setting to the rear of both was 101,336 pounds, which was within the                        flights, was 7-1/2 degrees above the certificated gross weight of the air-                           horizon and at a computed azimuth of 239 craft and properly distributed. The                             degrees. Wind was from west-northwest flight was cleared by CAA Air Traffic                           at 10 miles per hour . Control to proceed to the Shannon Air-                          During this period, between 1620 and port, Shannon, Eire, on an Instrument                           1622, both aircraft were observed to Flight Plan, and to climb en route from                         converge without any apparent change in LaGuardia to an altitude of 17,000 feet                         direction, or attempt to avoid colli- in accordance with Visual Flight Rules.                         sion, and the Cessna appeared to remain Approximately one hour before Pan                               in level flight. They collided at sq Americans Flight 100 departed from La-                         altitude of 3,500 feet over Port Wash- Guardia, at 1505, the Cessna 140 took                           ington. The Cessnas engine, propeller, off from Meriden Airport, Meriden, Con-                         landing gear, and seat structure entered necticut, which is approximately 80                             into and remained in the fuselage of the miles northeast of LaGuardia Field. So                          Constellation, the remaining parts of far as is known, Arthur R. Butting, the                         the Cessna and a few fragments of the owner of the aircraft, occupied the left                        Constellation fell into the congested seat and handled the controls, and                              area of Port Washington. Immediately Eugene Kowalczyk rode in the right seat                         before the collision, Captain Knuth saw as passenger. Before departing, Mr.                             the Cessna, but at that time it was Butting and Mr. Kowalczyk stated that                           within the wing span of the Constella- tion to the right of and slightly above the cockpit. Although the control col- All times referred to herein are Eastern Stand-               umn was pushed sharply forward, ard and based on the 24-honr clock. ---15683                                                        (1)  nosedown, it was too late to avoid the                       axis of the Constellation formed an angle of 38 degrees. An iapresnlon on Although the top of the Constellation                        the right forward side of the Constella- fuselage forward of the cabin and aft of                     tion fuselage had been made by the left the flight deck was torn and crushed,                        landing gear tire of the Cessna and U2 the airplane continued to fly satisfac-                      this impression was clearly stamped t-hs torily. An emergency landing was made                        trade mark of the tire manufacturer. The at the Air Forces1 Base, Mitchel Field,                      left landing gear strut, a solid piece of Mew York, 8 miles south of Port Washing-                     spring steel, left a clear outline of its ton. All occupants deplaned without                          shape in the skin of the fuselage where difficulty, and no injuries to those in                      it had entered Into the Constellation* the Constellation were Incurred as a re-                     Both the front and rear left wing sult of the accident. The two occupants                      struts of the Cessna were crushed and of the Cessna were killed at the time of                     curved to approximate the curvature of impact.                                                      the Constellation fuselage. Mo crushing was found on the leading edges of these Investigation                                 wing struts, but the trailing edges showed that they had been in direct con- Damage to the Constellation resulting                         tact with the Constellation. from the collision was confined to the                        The Cessna propeller entered thetop forward portion of the fuselage. Before the accident, the aircraft was in                      right side top of the Constellation fuse- lage near the window line and came out at an airworthy condition with all compo-                        the top of the fuselage just aft of the nents, including radio, operating nor-                        astrodome* One blade was relatively un- mally. The windshield was clean. The only possible obstructions to vision                          damaged but the other was bent forward. were the aircraft structure itself and                        The propeller was removed from the Cessna the magnetic compass which was mounted                        'engine and placed in the slash that itat the bottom center of the windshield.                       had made. A line was placed in the Unobstructed vision on a level plane is                       center of the hub and extended to the ii              -i not available to either the pilot or the                      tersection of the longitudinal axis ofcopilot in the cockpit of the Cons tell a-                    the Constellation, the angle of which tlon*Aircraft structure between portions                      measured 58 degrees. of the windshield restricts the crowds                        At the time of the accident, no clouds Vision in certain limited areas.                              existed below 15,000 feet, and the sur- So Tar as could be determined from                            face visibility on the ground was 10 aircraft records pertaining to the Cessna                     miles or better. However, fro the 140 and from those who were acquainted                        ground to 3,500 feet there was haze and with the aircraft, it was also In an                          smoke which was fairly evenly distributed airworthy condition prior to the time of                      to the area east of LaGuardia; winds the accident. The windshield was clean                        aloft between 3,000 and 4,000 feet were and free of cracks. Relatively clear                          from 320 degrees at 10 to 15 miles per and unobstructed horizontal vision was                        hour. Ab previously stated,               the sun at available from the pilots seat of the                        the time of the accident had an az 1 with Cessna from straight ahead to 90 degrees                      of 239 degrees and an altitude of 7.3, to the left and almost vertical in a                          degrees. downward direction. The greatest por- tion of the Cessna wreckage fell in the                       Analysis congested area of Port Washington. This                       All evidence found in the axaaioatinn included the left and right wing panel,                       of the wreckage, such as the scuff Mark, the engine cowl, fuel tanks, and the                          and the propeller slash left in the fuse- various parts of the empennage. The en-                       lage of the Constellation, showed that gine, propeller, and both landing gears                       the two aircraft converged at an approxi- of the Cessna, as stated above, remained                      mate angle of 58 degrees, the Cessna - be- inside the Constellation.                                     ing to the right of the Corustfll latlon- The bottom of the Cessna engine cowl                          This is supported by the fact that the left imprinted scuff marks on the top of                      difference between the heading of the the Constellation fuselage. The lines                         Constellation, as testified to by the of these scuff marks when extended rear-                      pilots, and the estimated heading for the ward so as to intersect the longitudinal                      Cessna on its return flight to ---16683 From PilotManuals.com / RareAviation.com Accident Investigation Report                                                            3 was 55 degrees, or approximately the samevicinity, especially In view of the fact as the above computed convergence angle    that he was crossing an airway in an area of 58 degrees. As the two airplanes con-   where heavy traffic could be expected. verged the Cessna was at a relative bear-  Furthermore, since the accident occurred ing of 38 degrees right from the Constel-  at 3,500 feet In a control area at a time lation, and the Constellation was at a     when the Cessna was observed in level relative bearing of 84 degrees left from   flight, It appears that the Cessna was the Cessna.                                not being flown at a proper altitude. Because of the position of the two         Therefore, It must be concluded that the airplanes, the Cessna was behind struc-    failure of the pilots In both aircraft tural members and the compass In the       to remain alert in an area where heavy con- windshield of the Constellation, and       centrations of traffic could be expected, could not be seen readily by either the    resulted In this mid-air collision. pilot or the copilot. However, if they     Findings had shifted to the side in their seats, or leaned forward or backward, they could have cleared their line of vision so that  On the basis of all available evi- the Cessna would have been observed.       dence the Board finds that: Consideration must also be given to the    1. The air carrier, .the aircraft, and fact that the Constellation could have     the crews were properly certificated. been seen from the Cessna, for the visi-   2. The Constellation and the Cessna bility In the Cessna from the pilots      were in an airworthy condition and oper- seat extended In a horizontal plane from   ating without any mechanical trouble straight ahead to 90 degrees to the left   prior to the time of the accident. and nearly vertical in a downward direc-   3. At the time of the accident there tion. Since both airplanes continued on    were no clouds below 15,000 feet and collision courses until impact, It Is      visibility at 3,500 feet was five miles reasonable to conclude that neither the    or better. pilots in the Constellation nor the pilot  4. The Constellation was climbing to In the Cessna observed the other until     its approved cruising altitude of 17,000 leaned lately before the accident.         feet at an indicated air speed of 175 The Civil Air Regulations applicable       ITes per hour and on a beading of 95 at the time of this accident, visibility   degrees, during which time the Cessna, being five miles or better, required an    en route to Meriden, Connecticut, from aircraft which was overtaking another, or  New Tork, was flying a heading of ap- converging on another from the left, to    proximately 40 degrees at an air speed give way. The same regulations also re-    of 108 miles per hour and at an altitude quired an aircraft in level flight when    of 3,500 feet. 3,000 feet or more above the surface In a  5. The two airplanes converged at an control area to fly at an even or odd      angle of 58 degrees and collided at an thousand foot altitude as specified by     altitude of 3,500 feet over Port Wash- the Administrator. In this particular       ington, New Tork, on Red Airway 23, case the Administrator had specified an    6. During the period of time that odd thousand foot altitude. In addition    the airplanes were converging at an to these specific regulations, the pilots  angle of 58 degrees, the Cessna main- In the safe operation of both aircraft     tained a constant relative bearing from were required to remain vigilant for the   the Constellation of 38 degrees and the presence of other aircraft In their im-    Constellation maintained a constant mediate vicinity.                          relative bearing from the Cessna of 84 It appears clear that the pilots in         degrees. the Constellation were required not only   7. Neither the pilots In the Constel- to see the Cessna, but to avoid It. It     lation, nor the pilot In the Cessna ob-also appears clear that the pilot in the   served the other until Immediately be- Cessna was required to remain alert for    fore impact though each aircraft could the presence of other aircraft In his      have been seen from the other. Accident InvestigationProbable Cause                                 could be expected, to re avoid the Constellation. The Board determines that the prob able cause of this accident was the             BT THE CIVIL             AERONAUTICS BO ABD t joint failure of the Constellation pi-                 I si JOSEPH J. O'CONE ELL, Jf. lots to observe and avoid the Cessna air-              Is/ OSWALD RYANcraft in flight, and of the Cessna pi-                 I si JOSH LEE lot, while on an airway and in an area                 Is/ HAROLD A. JONES where a heavy concentration of traffic I               I si RUSSELL B. ADANS---15803 Supplemental DataInvestigation and Hearing                       with a private pilot rating. At the time The Civil Aeronautics Board received            of the accident he had a total of 250notification of the accident on January         hours of flight time in light type air- 30, 1949, at approximately 1655, by tele-       craft. His last CAA medical examination phone from CAA Communications, LaGuardia        was passed October 20, 1947. His CAA Field, New York, and immediately Inlti-'        certificate showed that his vision was a ted an investigation in accordance with       normal as corrected by glasses. Although the provisions of Section 702 (a) (2) of        it could not be determined that he was the Civil Aeronautics Act of 1938, as           wearing glasses at the time of the acci- amended. As part of the investigation           dent, his glasses were found with his the hearing was held March 1, 1949, in          body. Eugene Kowalczyk, age 35, held a New York.                                       currently effective airman certificate Air Carrier                                     with a private pilot rating. At the time of the accident he had a total of approx- Pan American Airways, Incorporated, is          imately 105 hours flight time in light a New York Corporation with head offices        type aircraft. His last CAA medical ex- at 135 East 42nd Street, New York 1, N.Y.       amination had been passed July 7, 1947, The company holds a certificate of public       The Aircraft convenience and necessity authorizing it to engage in air transportation between         NC-86530, a Constellation, was an New York, N.Y., and London, England.            L-749, purchased June 28, 1947. The air- Flight Personnel                                craft was owned and operated by Pan Captain Knuth, age 31, held a cur-              American Airways, Inc., and was currently certificated by the Civil Aeronautics rently effective airline transport rating       Administration. It had been flown a to- and at the time of the accident had a           tal of 3,561 hours since the time of its total of 5,747 flying hours, 2,086 of           purchase, and had accumulated 5:52 hours which were in Constellation type air- craft. Re had been employed by Pan              since last major overhaul. The four American Airways since May 5, 1941. His         Curtiss-Wright engines, model No. last CAA physical examination was on            749C18BD1-2250, one through four respec- November 24, 1948. First Officer Wade,          tively, had been flown 1,574, 1,618, age 34, held an airman certificate No.          1,700 and 1,568 hours. The propellers 26528 and an airline transport rating. I        were Curtiss Electric, model No.C632 At the time of the accident he had a to-        SA14. tal of 5,307 flying hours, of which             NC-76891, the Cessna airplane, in- 1,993 were in Constellation type air-           volved in this accident, was currently craft. He was employed by Pan American          certificated by the Civil Aeronautics Airways on June 1/ 1943, and his last           Administration. The engine was a Conti- physical examination was accomplished on |      nental C-85-12. Total time for aircraft January 28, 1949.                           j   and engine was 324 hours. The propeller Arthur R. DuttIng, age 57, held a j             was a McCauley 1A90 CF7148, and had a currently effective airman certificate ]        total time of 308 hours. ---15683                                                           (D APPENDIX IN.1RELATIVE BEARINGS OF 38,* CESSNA FROM CONSTELLATION. AND 84* CONSTELLATION FROM CESSNA, REMAIN CONSTANT THROUGHOUT PERIOD THAT BOTH AIRCRAFT ARE ON COLLISION COURSES. ---15683                                                         (II) Filo r!o. 1-0002CIVIL AERONAUTICS BOARDACCIDENT INV:          TIGATION REPORTAdootod: May 8, 1951 Released; May 10, 1951 PAiT AMERICAN WORLD AIRWAYS, INC., LOUDON, ENGLAND, JAiUJftRY 3, 1951The Accident >C At approximately 085OZ", Jamary 3, 1951, a Boeing 377 Stratocruiser, LI-1036V, owned and operated by Pan American World Airways, was considerably damaged when the right main landing gear retracted during a landing at Heathrow Airport, London, England. There wore no passengers on board and the crew of nine were uninjured. History of the Flight The aircraft, N-IO36V, arriving in the London area on January 2, as Pan Americans Flight 100/01 from the United States, was diverted to Hurn, England, due to the London weather being below minimums. The trip from the United States had been routine and the landing was made at Hurn at 0923. At 1100 the weather at London was still below minimums whereupon it was decided to send the passengers to London by train and to ferry the aircraft to London on the following morning to cover the return Flight 101/03 to the United States. At 0803, January 3, the aircraft departed Hurn for the ferry flignt to London, a distance of 79 statute miles. On board were the original crew of Flight 100/01 from the United States consisting of Captain A. L. McCullough, First Officer J. A. Livers, Second Officer P. Ridley, Third Officer John Race, First Engineer L. J. Fleishman, Second Engineer R. E. Lee, Purser J. Swirstik, Stewardess M. McFarland, and Supernumerary 0. Mazurek* * All times noted in this report are Greenwich Meridian and based on the 21j-hour clock. KAA Library' The take-off weight of about 103,576 pounds was approximately b.2,000less than the maximum permissible and the load was so                                                                                             distributed that thecenter of gravity was within the                                                  c        certificated limits.                                      The runway at Burnwas covered with heavy frost or light snow.                                                                        However, with the temperatureat 28.,^F., it was not wet or slushy. The London Meteorological Officegave the London weather at 0900 as "high scattered, visibility 3,300 yards,wind 300/08, temperature 32.2.                                                            The flight plan for this ferry trip carriedthis notation, "runway braking conditions good at run-up or touchdown, tofair further down runway due slush. This notation taken from the dis-patcher 1 s                                    clearance referred to the                                 conditions                  ,t London where portions ofrunways were covered Tilth three to four inches of snow and slush* The flight proceeded norinally at altitudes varying from 6,000-7; 000 feet with outside temperature about 5>F< A practice GCA approach was made followed f E I- by what at first appeared to be a normal landing on Runway 28 at O85O. During the landing roll, however, the rignt main landing gear retracted < permitting the plane to settle down on the Ho. 3 and Io, h engine nacellesand the right wing.                                                                                  In this position it skidded to a stop, partly offthe runway after turning approximately 110 degrees to the right.                                                                                                 Therewas no violent deceleration and only a slight change of direction downthe runway.Investigation The aircraft came to rest U,58O feet from the approach end of Runway 28,which is 9,h5O feet in length.Major damage to the aircraft was confined to the right wing tip, raileron and flap and to the propellers and nacelles of IJo. 3 and LTo, It engines . The first contact of a propeller with the runway was noted l,01i0 feet from, where the plane came to rest. Scattered along the runway from this point were various pieces of propeller, propeller filler material, and small pieces of dural. The runway along the portion over whicn the aircraft traveled was covered with slush from the previous day for which reason it was extremely difficult to establish with certainty the exact point of initial touchdown The GCA practice approach and landing was made by First Officer Livers occupying the right or copilot seat. Captain McCullough was in the left seat and took over some of the duties ordinarily performed by the first officer. Due to the known condition of the runways it had been previously decided to use 30 degrees of flap on landing to prevent, insofar as possible damage to the flaps by snow and ice being thrown against, them during the landing roll. Cep tain McCullough placed the initial touchdown at a point approximately 1,UOO feet past the approach end of the runway. He described the landing made by First Officer Livers as a "beautiful landing---very slightly nose up" with the main gear touching down at an indicated air speed of about 110 knots. The nose wheel became grounded almost immediately. The captain reversed No. 2 and No. 3 propellers. After unreversing and noting the slush was getting deeper, he decided to raise the flaps. However instead of actuating the flap switch, ho mistakenly moved the landing gear switch to the "up" position. Although it was immediately returned to the -*Noto: The gear operating switch is located on the control pedestal approxi- mately 21; inches forward of the flap sxiitch. It is further protected against inadvertent movement by a hinged guard which must be raised before the switch toggle can be operated. "down" position the landing gear warning horn sounded, and shortly thereafter /tne right wing began to drop.Competent ground witnesses all agreed, that the landing was very smooth.They variously estimated the point of touchdown as anywhere between 2 .,600to 3>O6o feet                                           down the runway but indicated that the actual point of touchdown was difficult to determine accurately.There is no testimony or evidence which would indicate tnat the brakeswere at any time effectively appliedAn examination of the runway surface was ra.de by competent personsprior to the arrival of the Civil Aeronautics Board investigators -todetermine if possible the cxaci pomt of                                              initial touchdown, The runway hadbeen used the proceeding nigno after tl                                              snowfall and is a result all landingmarks were not entirely distinguishable                                                  However, from the evidence available the touchdown point was placed at approximately 1,200 to l,U00 feetpast the runway approach endA thorough examination was made of the right main landing gear andall. of its components, following which operational and functional testswere conducted. No mechanical or electrical failure of the gear or gearcontrol system, was found and all tests indicated normal operationEach landing gear oloo strut is equipped with two micro-switches whichare actuated when the landing gear wheel is grounded firmly enough to compressthe strut approximately one-half inch of its travel. These switches are apart of two entirely separate .safety systems, rhe purpose of one being:to prevent the throttles being moved into the reverse thrust positionbefore the aircraft is grounded,                                   the purpose of the other, to preventn extended landing gear from being retracted after it is firmly groundedeven though the landing gear control switch is placed in the gear "up" position. However, it is not necessary that all three landing gear units be firmly on the ground before the throttles can be manually moved into the reverse thrust position. This can be accomplished as soon as any one of the landing gear units is supporting sufficient weight to actuate tho appropriate micro-switch. However, if the landing gear control switch is placed in the gear "up" position during landing roll, any landing gear unit will unlock and retract if there is not sufficient xieight main- tained to hold the micro-switch in its actuated position. Later the micro-S.Titch concerned was removed from the right gear and further examination and functional tests conducted under tho supervision of a Board investigator at tho instrument shop of the Pan American World Airways at International Airport, New York. To simulate a condition possibly existing at the time of the landing at London, the spring-loaded switch plunger was compressed and wired in the closed position. The protecting rubber boot was then filled with water and the switch packed in dry ice until tho water was frozen. When tho wire was cut the plunger still functioned normally opening the circuit to the landing gear operating motor. With the circuit open the gear will not retract. This test was repeated with the same result. The switch itself was than disassembled for inspection. All parts were found to bo in excellent working condition. Analys is There are two situations which could account for the retraction of tho right main landing gear, had either existed at tho time the gear control switch was momentarily placed m tho "up" position: (1) mechanical or electrical malfunctioning of the landing gear control system including thesafety switch;                                    (2) insufficient weight          on tne right gear      to actuate thesafety switch or to hold it in its actuated position throughout the landingroll, Exhaustive tests failed to reveal any evidence of mechanical orelectrical malfunctioning of the landing gear control system. It must,therefore, be concluded that there was not sufficient weight on the landinggear to actuate the safety switch at the moment the gear control switch wasmoved to the 'up1 position.s! indingsOn the basis of all available evidence the Board finds that:1. The carrier, the aircraft and the crew were properly certificated.2. The runway surfaces at Heathrow Airport were covered with slush; 's however                  conditions were satisfactory for landing.The landing was smooth, the aircraft touching down approximately1,UOO feet past the approach end of a $,U>0-foot runway.There was no malfunctioning of the aircraft or any of itscomponents prior to the accidentThe landing gear operating switch was moved to the gear "up"position during the landing roll. - 7 - Probable Cause The Board determines that the probable cause of this accident was the captains action in mistakenly placing the landing gear control switch jn the Hupn position during landing rolla BY THS CIVIL ^PONaUTICS BOaRD: /s/ QffT'JLD K /s/ JOSH LEE /s/ JOSEPH P. AD.J.S /s/ CHaN GURIIEY SUPPLEMENTAL DATAInvestigationThe Civil Aeronautics Board received notification, of the accidentat New York.                                                                                                       investigation was immediately initiated in accordancewith the provisions of Section 702                                                                                                                                                    (a)(2) of the Civil Aeronautics Actof 193                                                                                     as amended.                                 Two air safety investigators were immediatelydisnatched to the sceneAir CarrierPan American World Airways,                                                                                                                    Inc., is a New York corporation with headoffices at 13$ East 14.2nd Street,                                                                                                                                         Pew York 1, Dew York.               The company holdsa certificate of public convenience                                                                                                                                                        and necessity authorizing         it to engagein air transportation between New York, Low York, and London, England.Flight PersonnelCaptain A. L. McCullough, age 54, was employed by Pan American WorldAirways, November 1, 1933 He had accumulated 8,752 hours on Pan American equipment, of which 1,269 wore on tno type of equipment involved. Hehold a valid airline transport pilot rating. His last instrument checkwas                                                                                    accomplished on October 23, 1950, and route chock December 24, 1950.First Officer J. A. Livers,                                                                                                                      ge 29, was employed by Pan American Worldf irway s,                                                                       November 1, 1942.                                                           His total time on Pan American equipment was 146,028 hours,                                                                                  of which 1,318                                                  were on the type of equipment involved.Both pilots were fully                                                                                               qualified to fly the Booing 377.Tne AircraftN-1036V,                                               a Boeing 377, was rcnufacturod by the Bo e Wig Airpiano Company,Seattle, Washington,                                                                                                                and was currently certificated as airworthy. SA-237                                                                                                   File No. 1-0053CIVIL AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: November 29, 1951                                                        Released: December 5, 1951PAN AMERICAN WORLD AIRWAYS, INC.---NEAR MONROVIA, LIBERIA, JUNE 22, 1951THE ACCIDENT                                                                  with the flight plan At 0057 a position Pan American World Airways Flight 151 of                                     report was given over Abidjan, 258 milesJune 21, 1951, a Lockheed Constellation L-                                    west of Accra, and arrival over Cape Palmas, Liberia, 265 miles farther to the west, was 049, N 88846, en route from Johannesburg,                                     estimated as 0156 At 0156 Flight 151 re- South Africa, to New York, New York, crashed                                  ported over Cape Palmas at 16,500 feet MSL, at approximately 0325Z1, June 22, about 54 miles2 northeast of its next scheduled stop,                                  on instruments, and estimated arrival at Roberts Field, Monrovia, Liberia The 31                                       Roberts Field as 0246 (A plantation employ- passengers and crew of nine were all fatally                                  ee in the Cape Palmas area stated that he heard an airplane inland and very high at injured and the aircraft was destroyed                                        approximately 0220, that the moon was bright HISTORY OF THE FLIGHT                                                         and the sky was clear at the time Since no Pan Americans Flight 151 departed Johan-                                     other aircraft was known to have been m the nesburg at 0812, June 21, and after a routine                                 area, this is presumed to have been Flight flight and scheduled stop at Leopoldville,                                    151 ) At 0220 Flight 151 requested clear- ance to descend Roberts Field radio Belgian Congo, arrived at Accra, Gold Coast,                                  cleared the flight to descend to 3,000 feet at 2125 Following a mechanical delay which                                    and advised that at 0225 the Roberts Field required the changing of several spark plugs                                  tower would establish contact on VPF A and a set of magneto points, the flight was                                   clear two-way contact was made at 0225 on dispatched and cleared to Roberts Field,                                      118 1 mes, at which time the tower gave the Monrovia, on an instrument flight plan at                                     flight the local weather and altimeter set- 16,500 feet with Dakar, French West Africa,                                   ting, cleared it to descend IFR over and Accra as alternates Take-off from                                         Roberts Range Station, and indicated that Accra was at 2352Z The gross weight at departure was 8Q,255 pounds, including cargo,                                 Runway 05 was in use At 0237 Flight 151 was again given local weather for Roberts mail, 3,340 gallons of fuel, 31 passengers,                                   Field cloud base estimated 1,000 feet, and a crew of nine The gross weight of the                                    broken, light drizzle and haze, visibility 3 aircraft and distribution of the disposable load were within the allowable limits                                         miles At 0241 the local wind was given as The en route communication system of the                                      M-WW variable 7 miles per hour All of flight sector between Accra and Roberts                                       these messages were acknowledged Field is high frequency radio-telephone                                       At 0255, nine minutes after its ETA at Roberts, Flight 151 was heard calling utilizing ground stations at Accra and                                        Roberts Field pn VHF 118 1 mes The tower Roberts Field as primary guarding stations                                    responded, repeating the call three times Normal coirmunication with these two stations                                 There was no indication that the aircraft was maintained as Flight 151 progressed                                       heard the tower, whereupon the tower westward after departing Accra                                                switched to 3270 kes and requested the flight The flight proceeded in a routine manner,                                     to give its current position There was no climbing to 16,500 feet MSL in accordance                                     reply to this call Immediately following failure of the aircraft to respond to Roberts tower on 3270 kes, the Roberts Field1 All times referred to herein are Greenwich                                  high frequency radio-telephone facility Civil and based on the 24-hour clock                                          established contact advising the flight that 2 All distances given are in statute miles Conn---DC---38751                                                                        (1) See our selection of aviatioon documents at RareAviation.com Accident Investigation-Reportthey were unable to read it on 118 1 mcs and                                   components were found at the scene, and no that the flight should reply to the towers                                    evidence was found to indicate that any partcall on 3270 kcs This message was acknow 1*                                    had become detached prior to impact An ^dged at 0301 At 0305 the flight again                                         intense flash fire over the entire area of contacted Roberts tower on 3270 kcs advising                                   wreckage distribution and several localized that the Dakar radio beacon was interfering                                    fires followed impact, but there was no with the Roberts Field radio beacon and that                                   evidence of any inflight fire they would "be back m 15 minutes " Roberts                                     The propeller dome settings indicated tower advised Flight 151 that Dakar would be                                   that all four engines were producing approx- requested to turn off the beacon and this                                      imately the same amount of power The cock- message was acknowledged (Because of in-                                       pit instruments recovered were too severely coming traffic to Dakar, the beacon there                                      damaged to give any reliable indications of was not turned off until 0410 ) At 0315                                        their readings when the crash occurred flight 151 again called Roberts tower on                                       Statements of eyewitnesses and stopped 3270 kcs and the latter transmitted the                                        watches which had been worn by occupants of latest weather The flight did not acknowl-                                     the aircraft indicated the time of impact as edge this transmission on 3270 kcs but called                                  approximately 0325 At this tune the air- Roberts tower on 118 1 mcs Roberts tower                                       craft had about eight hours of fuel remain- then replied on-118 1 mcs but received no                                      ing, having departed Accra with over eleven acknowledgment Thereafter, the tower re-                                       hours of fuel aboard peatedly called Flight 151 on both 118 1 mcs                                   A thorough review of maintenance records and 3270 kcs, requesting the aircrafts                                        for the aircraft reflected no irregularities position and broadcasting the weather How-                                     and indicated that the aircraft was air- ever, the incomplete contact at 0315 was the                                   worthy when it departed Accra last transmission received from the flight                                     The weather at Roberts Field, available At 0410 emergency procedures were initi-                                       at Accra before the flights departure, was ated at Roberts Field and at 0515 an alert                                     ceiling 3,500 to 5,000 feet and visibility notice was dispatched to appropriate sta-                                      better than 5 miles Although the weather tions that Flight 151 was still unreported                                     information available is rather incomplete, and that aerial search would begin at day-                                     it appears that at Cape Palmas the flight light Ekinng the day of June 22 aerial                                         should have been m the clear on top at its search was conducted but was not successful                                    assigned cruising altitude of 16,500 feet, in locating the missing aircraft The first                                     and that the outside temperature was about definite information received was when a                                       31 and the wind from approximately 80 at foot messenger arrived from the village of                                     20 knots In the vicinity of longitude 10 Sanoye at approximately 1430, June 23, with                                    to 11W, a rather extensive cumulo-nimbus word that m the early morning hours of June                                    development appears to have existed, with 22 an aircraft had crashed into the side of                                    the heaviest rain east to northeast of a hill 2 4 miles west of his village, and                                      Roberts Field It is probable that the that everyone on board was killed Lack of                                      flight flew into this cumulo-nimbus develop- communication facilities between Sanoye and                                    ment, resulting m bad static and heavy Roberts Field precluded earlier notification-                                  rain I                                                                              In the vicinity of the crash, the flight THE INVESTIGATION                                                              was east of the line of storms but the cloud Investigation at the scene indicated that                                      bases were probably down to near the hill- the aircraft struck at high speed in a later-                                  tops Witnesses who heard the aircraftally level and slightly descending attitude                                    flying northerly, and then saw it flying low at an elevation of 1050 feet MSL/ with the                                     on a southerly heading just prior to the wing flaps, landing gear, and landing lights                                   crash, stated that the night was dark but no in the retracted position The wreckage was                                     rain was falling, although there had been a distributed about a line running 178                         mag-             heavy rain earlier in the evening No lie tic from the point of impact                       All major               important turbulence appears to have been likely m the unnediate vicinity of theThe minimum en route altitude                      for the area in              crash area and surface wind is believed to which the crash occurred is 6,500                  feet                         have been very light 3Weather at lhe alternates---Accra and             ANALYSIS Dakar---was above minimum and remained so        The last reported position from Flight throughout the period that Flight 151 might      15.1 was at 0156 over Cape Palmas, on instru-have arrived at either of those points, had      ments at 16,500 feet Since Cape Palmas has the captain elected to proceed to one of his     no radio facility this position must have alternates                                       been determined by dead reckoning or a ce- The Roberts Field radio navigational aids        lestial fix From Cape Palmas to Roberts consist of a 100-watt standard MRL type          Field, a distance of 231 rules, a change of radio range, with which is associated a 5-       heading is required from 275 v1 to 310M watt Z marker beacon transmitter In addi-        Ibis new heading is almost identical to the tion, there is a 1200-watt radio beacon which    toward-the-station heading of the southeast was operating on a frequency of 400 kcs at       leg of Roberts range, which ls 317M the time of the accident u These facilities      'lhe next contact with the flight was at are not considered primary long-range naviga-    0220, at which time clearance to descend was tional aids but rather are localizers for the    requested Clearance was granted via radio- purpose of instrument let-down and landing at    tele pnone to descend to 3,000 feet At Boberts Field after arriving in the area 4 4 5   0225 Roberts Tower gave the flight local However, all Pan American flights through        weather and cleared it to descend IFP over Roberts Field carry a qualified navigator as     the range station Although competent per- part of the crew Testimony of pilots ex-         sonnel at Roberts Field were waiting on the perienced m using these facilities indicates     ramp and listening for the arrival of Flight that 50 miles is the maximum distance for        151, it was never heard either before or effective reception of the radio range, with     after its ETA, 0246 From this it must be 75 miles for the radio beacon, under weather     concluded that the flight not onlv failed to conditions similar to those existing the         overhead the range station, but also never night of the accident                            reached the general area of Roberts Fiela The minimum en route altitude from Cape          lhe flight was nineteen minutes beyond Palmas to Roberts Field, when not moi e than 5   its ETA at Roberts when it reported that miles either side of a direct route, is 4,500    the Dakar beacon was overriding the Roberts feet, when outside these limits, tht minimum     beacon This, together with the location of altitude is 6,500 feet There are no radio        the crash, leads to tne conclusion that the navigational aids along the route, and prior     flight at this time was beyond the effective to arriving within effective recept on range     range of the Roberts beacon As a result of of the Roberts field aids, the only means by     this and previous reports of interference which a flight can determine its position        from Dakar, the freouency of the Roberts under instrument conditions is dead reckoning    radio oeacon was changed to 372 kcs to pro- or a celestial fix                               vide a greater separation of frequencies Ihere were no reported malfunctions of the       between the two beacons However, had the navigational aids at Roberts Field during the    flight been m the immediate vicinity of tine Flight 151 was within range, w th the       Roberts Field, interference by the Dakai exception of the reported interference of the    beacon would not have precludes a landing, Dakar beacon, operating on 403 kcs No air-       since the radio range, which was functioning craft was heard passing over or neai Roberts     normally, is the facility provided and Field during the time Flight 151 was expected    normally used for instrument aooroach to arrive, although competent personnel were     In the absence of any indications of waiting and listening for it, and the flight     mechanical trouble, there is no logical ga/e no position report of any kind except       explanation for tne captain's action jr the statement, will be back in 15 minutes "    descending without having positive knowledge of the flights position 6 It must be con- cluded, therefore, that be made this descent with the mistaKen belief the (light s posi- tion was such that he ccuxo safelv aescend 4 On July 21, 1951, the frequency of Roberts Field radio beacon was changed fron 400 kcs to 372 kcs 5 See Aopendix "A"                                             6 See appendix B1* Accident Investigation Reportbelow the prescribed minimum altitude There                      FINDINGS was no known necessity for immediate descent                     On the basis of all available evidence, as the flight still had ample fuel to pro-                       the Board finds that ceed to either of its alternates, Accra or Dakar, and weather at both remained above                        1  The                  carrier, crew and aircraft were minimums during the time the flight might                        properly certificated have arrived at either point                                     2  The gross weight of the aircraft andOn July 24,                 1951, Pan American World Air-       disposition of the disposable load were ways made a change in operating procedures                       within allowable limits and issued the following instructions to all                     3  There was no malfunctioning of the personnel concerned with African flights                         aircraft or any of its components prior to the accident, nor was there any malfunc- UNTIL FURTHER NOTICE MINIMUM INSTRU-                             tioning of the navigational aids of Roberts MENT APPROACH ALTITUDE ROBERTS FIELD                             Field 8,000 FEET AIRCRAFT WILL LOSE ALTI-                              4 Weather at Roberts Field was above TUDE BY THREE MINUTE SHUTTLES ON THE                             minimums at the time Flight 151 was expected SOUTHWEST ROBERTS FIELi                     RANGE LEG RE-        to arrive and remained so throughout the PORTING EACH ONE THOUSAND FEET, PRO-                             night CEDURE TURN, AND RANGE OVERHEAD                                  5  At the time of the crash the flightINSTRUMENT APPROACH SHALL START FROM                             had ample fuel remaining to have proceeded RANGE OVERHEAD WITH VISUAL AND AURAL                             to Dakar or returned to Accra, its desig- "Zn MARKER INDICATIONS AND BE EXECUTED                           nated alternates IN ACCORDANCE WITH MANUAL PROCEDURE                              6  The aircraft never overheaded the WITH AIRCRAFT REPORTING INBOUND PRO-                             Roberts Field range station and a let-down CEDURE TURN, LOW CONE, FIELD NOT IN                              was made without positive determination of SIGHT OR MISSED APPROACH *   *                                   the flights position.As a result of a survey of the naviga-                                   PROBABLE CAUSE tional facilities at Roberts Field by the Civil Aeronautics Administration subsequent                      The Board determines that the probable to the accident, Pan American World Airways                     cause of this accident was the action of theoperations into Roberts Field were, on                           captain m descending below his en route August 9, 1951, restricted to VFR day oper-                      minimum altitude without positive identifi- ations only                                                      cation of the flights positionSubsequent improvement m the Roberts                              BY THE CIVIL AERONAUTICS BOARD Field facilities resulted in this restric- tion being removed to the extent that PAWA                                                               (s/      DONALD W NYROP was authorized to return to the original                                                                 Is/ OSWALD RYAN operations specifications, except that all                                                               I si JOSH LEE night operations are to be m accordance                                                                  Is/ JOSEPH P ADANS with IFR rules                                                                                           Is/ CHAN GURNEY---38751 APPENDIX "A" ACCIDENT NEAR MONROVIA, LIBERIA, JUNE 22,1951ROBERTS FIELD ELEVATION 25///MIN EN ROUTE ALT N                                     WITHIN 50 Ml <V                 4000 * VAR I7W                                                      V 550380 <5 MIN EN ROUTE ALT                                                                ^IlgOO'-h WITHIN 50 Ml                                  ROBERTS                                              A 3000                                       FIELDRANGEAMARSHALLMIN EN ROUTE ALT WITHIN 50 Ml N                            3000                    * MIN ENROUTE ALT WITHIN 50 Ml 3000                                                                      O 2                   4    6    NAUTICAL MILESFACILITY                                RANGE   BEACON                          TOWER TRANSMfTS                   263      400        3270 118 1  126 9RECEIVES                                                     3270 118 1  126 9SAFE ALTITUDE RADIUS 10Ml 3000 25 Ml 3000   50 Ml 4000   100 Ml 400038584 Supplemental DataINVESTIGATION AND HEARING                                    L-49 equipment He was employed by Pan The Civil Aeronautics Board was notified                     American on June 16, 1Q41, and was qualified at 1145Z, June 22, 1951, that PAWA Flight                    as a captain on November 15, 1943 Captain 151 was overdue at Roberts Field, Monrovia,                  Crawford had had 305 hours of navigating Liberia, and that search and rescue facili-                  experience but he was not a certificated ties had been alerted The wreckage was                       navigator His last CAA physical examina- located in mid-afternoon on June 23 and the                  tion was December 12, 1950, his last route Liberian Government delegated                                check was April 8, 1951, and his last investigation         instrument check was June 10, 1951 of the accident to the United          States Civil Aeronautics Board The Board            immediately           First Officer G A Alcock, age 34, held initiated an investigation m           accordance            a valid airline transport rating and a cur- with the provisions of Section 702 (a) (2)                   rent radio-telephone license, and had flown of the Civil Aeronautics Act of 1938, as                     a total of 5134 hours, of which 2776 were amended, and investigators were dispatched                   in L-49 equipment He was employed by Pan to the scene A public hearing was ordered                    American on July 6, 1944, and was qualified by the Board and was held in New York, New                   as a first officer on June 16, 1945 His York, August 8, 9, and 10, 1951                              last CAA physical examination was May 15, At the Boards invitation, the Liberian                      1051, and his last instrument check was Solicitor General attended the hearing as                    March 3, 1951 his governments official representative                     Second Officer R F Detwiler, age 31, The Civil Aeronautics Board desires to ex-                   was the flights navigator He held comrer- press its appreciation of the cooperation                    cial pilot, and flight navigator certifi- extended by the Liberian Government during                   cates, and a radio-telephone license His the investigation of this accident                           experience consisted of 5,696 flying hours, of which 3027 were on L-49 equipment, and AIR CARRIER                                                  886 hours of navigation time Pan American World Airways, Inc , a New                      The remainder of the crew consisted of York corporation with its mam offices at                     Third Officer F S Bowne, Fourth Officer 135 East 42nd Street, New York, New York,                    G Havlena, First Flight Engineer F W holds a certificate of public convenience                    Bush, Second Flight Engineer G Kissling, and necessity authorizing it to engage in                    Purser R Tunstall, and Stewardess B air transportation between New York, New                     Pic ou York, and Johannesburg, th ion of SouthAfrica, with various stops en route, in-                     THE AIRCRAFT cluding Roberts Field, Monrovia, Liberia                     N 88846, a Lockheed Constellation Model L-049, had a total of 13,343 flying hours FLIGHT PERSONNEL                                             and was currently certificated by the Civil Captain F J Crawford, age 37, held a                         Aeronautics Administration It was equipped valid airline transport rating and a current                 with four Wright engines, Model 745C18BA3, radio-telephone license, and had flown a                     and the propellers were Hamilton Standard, total of 7818 hours, of which 426 were in                    Model 33E60, equipped with #-6801 blades ---38751 SA-2110                                                                                File No. 1-0074 CIVIL AERONAUTICS BOARDACCIDENT INVESTIGATION REPORT Adopted; March II, 1952 Released* March |4, 1952PAN AMERICAN WORLD AIRWAYS, INC., KINGSTON, JAMAICA, SEPTEMBER 2, 1951THE ACCIDENT                                                              emerging from the heavy part of the squall, At approximately 1010 EST/ September 2,                                   which was then over the approach end of Bun-1951, a Pan American World Airways' Convair                               way 14 and moving northwesterly At this 240, N 90662, being operated as Flight 507                                time the flight requested and received per- between Miami, Florida, and Maracaibo, Vene-                              mission to circle the airport to the right zuela, crashed in the water at Kingston, Ja-                              Witnesses located near the approach end of maica, about 800 feet short of the approach                               Runway 14 observed the aircraft flying in a end of Runway 14, the point of intended                                   southeasterly direction, paralleling the landing The 29 passengers, including one                                  runway At approximately the runway inter- infant, and the crew of four all escaped                                  section, 2 the aircraft turned right and con- serious injury The aircraft was demolished                                tinued around the airport to a point north- by impact and salvage operations                                          west of the approach end of Bunway 14 and over Kingston Harbor, here it was observed HISTORY OF THE FLIGHT                                                     to descend into the water about 800 feet Flight 507 departed Miami, Florida, at                                    short of the runway No one was seriously 0700, September 2, 1951, and made a routine                               injured scheduled stop at Camaguey, Cuba No irreg-                                A motor launch from a nearby salvage ves- ularities were reported by the flight crew                                sel arrived alongside the wrecked aircraft upon arrival at Camaguey, and the flight de-                              in a matter of minutes and took the survi- parted there on schedule at 0900, cleared                                 vors ashore The wreckage floated for a short under visual flight rules direct to Kingston,                             time, then sank, leaving only a part of the Jamaica, with Montego Bay, Jamaica, as an al-                             tail group and one wing visible above the ternate The gross weight of the aircraft                                  surface of the water and distribution of the disposable load were                              INVESTIGATION within allowable limits upon departure from                               Initial contact with the water resulted Camaguey The flight was uneventful between Camaguey                                in the right wing being tom from the fuse- and Kingston, and routine radio contacts were                             lage at the wing root, and the nose section made en route At 1003 Flight 507 reported                                 and cockpit structure breaking off at the its position to Palisadoes Airport Tower,                                 front entrance door frame located on the Kingston, as 20 miles north and a little                                  right side of the fuselage This nose sec- later was cleared into the traffic pattern                                tion went to the bottom in 20-odd feet of for Runway 14 The flight acknowledged this                                water, the captain and the copilot were able clearance and shortly thereafter reported                                 to extricate themselves, however, and that the field was in sight Palisadoes                                    reached the surface without injury Before Tower then advised Flight 507 of the presence                             the fuselage became fully submerged, all of a local squall between Kingston and the                                passengers either made their way forward in- approach end of Runway 14, with heavy rain at                             to the water through the opening created by the airport, and suggested a low approach                                 the missing nose section, or back and out When the aircraft first came into view of                                 through the emergency rear door One life the air traffic controller, it was just                                   raft had been inflated and several passen- gers placed aboard before the arrival of the 2 See Appendix A -All times referred to herein are Eastern Standard and based on the 24-hour clock Accident Investigation Reportmotor launch from the salvage vessel Cable,          Copilot Wrights statement (written m which was engaged m a dredging operation             the third person) concerning his initial ap-approximately 1,500 feet from the scene              proach to the airport reads as follows "The The wrecked aircraft sank to the muddy               Copilot descending VFR, crossed the Bay bottom of Kingston Harbor in about 24 feet of        towards the radio range and proceeded          to water with the outboard half of the left             Palisadoes Airport, dropping 15 flap en wing, the left stabilizer and elavator, the          route He rounded the squall?area to            the rudder, and the upper portion of the verti-          southwest and found himself too close          m to cal stabilizer remaining above the surface           attempt a landing " He states he then flew of the water                                         parallel to Runway 14, m the meanwhile re- Salvage equipment at Kingston was ex-                questing and receiving permission for a tremely limited Also, due to the ravages             right-hand turn and clearance to land of a severe hurricane which had passed               From the testimony of the captain and co- through Kingston on August 17, 1951, there           pilot, it would appear that the flight never was no telephone service available, and              entered the squall area on initial approach other communications, electrical power, and          to the airport Several passengers, however, transportation were greatly restricted This          stated that the aircraft passed through not only delayed the preparations for salvage        heavy rain on this initial approach Fur- operations, but made such operations very            thermore, the air traffic controller on duty difficult However, the major portion of the          at the time stated that at 1005 he requested wreckage was eventually raised, placed on a          the flights position and was advised that barge, and towed to the airport dock, where          it was just coming over the ridge and had it was thoroughly examined Meanwhile, a              the city in sight The controller further vessel equipped with grappling hooks dragged         states, "A few minutes later when I had 507 the area m an attempt to locate missing              in sight he was then approximately one-half parts of the aircraft Dredging operations            mile away and was just breaking through the were suspended temporarily to permit the             heavy part of the squall which was over the murky water to clear, after which two pro-           end of Runway 14 " fessional divers with special equipment were         Not only does the testimony of Captain flown in from Miami and their services were          Olsen disagree on several very important utilized October 4 through October 8 The             points with that of Copilot Wright as to combined salvage operations resulted in re-          what occurred between the time the aircraft covery of the major portion of the aircraft          rolled out on to final and the impact with Those parts not recovered consisted of the           the water, but their version of the last right engine, much of the right nacelle,             phase of the flight is m general conflict approximately two-thirds of the right wing           with the testimony of all ground witnesses including a section between the fuselage and         interviewed and with statements submitted by the nacelle, approximately one-half of the           several passengers as well right flap, and approximately one-half of            The following is quoted from Copilot the right aileron                                    Wrights statement concerning events inmedi- Among the items of immediate interest re- covered were two of the four right flap              ately preceding the crash "The final then tracks and carriages (Nos 1 and 3), and the          entered, Copilot stopped turning and called right engine nose section with the propeller at-     for full flap Runway was ahead and at a tached These indicated, respectively, that the       fairly steep angle Power was then reduced right flap was extended to the 33 position and      to approximately 28 ins mercury Copilot the right propeller was in low pitch at the          checked air speed at 120 knots and altitude moment of urpact Prior to the beginning of any       at 400 feet He then looked across to the salvage operations, the left wing, which was in-     Captain's side of the aircraft and checked tact, was examined This examination revealed         the power Upon checking the runway again, that the left flap was also extended to the 33 position and the left propeller was m            the Copilot noticed that the aircraft had low pitch A thorough examination of all              entered a right spiral descent Attempt was parts recovered failed to reveal any evi-            made to right the aircraft with aileron and dence whatever of malfunctioning of the air-         elevator No abnormal control pressures craft or any of its components                       were felt by the Copilot Captain Olsen, noticing the Copilots difficulty, attempted 3 See Appendix B                                      to help right the aircraft Aircraft ---39307 From PilotManuals.com / RareAviation.com continued to descend and entered the water      this increased bank began range from a mini- right wing first "                              mum of 60 feet to a maximum of 200 feet When asked the approximate angle of right       One of these witnesses, a former naval bank at the moment of impact with the water,    aviation metalsmith who was standing m the he replied, 45 to 50 degrees " When asked      motor launch that later picked up the survi- how far from the approach end of Runway 14      vors, stated, "I saw the plane approach from did he make his turn on to final, he replied,   the SW and as the plane passed the end of the "1,500 feet " He further stated that no at-     runway she started almost a 4-0-45 bank to tempt was made to reduce power, which at the    right and descending slowly at the same time time was 2600 rpm and 28 inches of mercury,     When the plane was off the end of the runway before striking the water The aircraft was      and still in a turn she seemed to slip right closely aligned with the centerline of Run-     wing down toward the water When the right way 14 extended and a survey showed that when   wing hit the water the bank was less than 40 it sank, the nearest part of the aircraft was   almost 10 bank The right wing hit first, 798 feet from the end of the runway             then the landing gear hit after she had When Captain Olsen was asked if he con-         skipped a little bit, then the nose hit the curred with the copilot as to the attitude      water * *   " Tins estimate of the air- of the aircraft just before striking the wa-    crafts attitude at impact coincides with the ter, he replied, "Well, I dont concur with     captains testimony that he believed the air- his attitude there I assumed it was in a        craft at impact was much closer to level than more level position---just before contact* * *  was estimated by the copilot Several of the when I eventually got on the controls, as I     passengers stated they thought a landing had say, the aileron had Deen at full travel---     been made on the airport until they saw water full travel had been accomplished---and there   coming into the aircraft was no bringing the right wing up, and the      ANALYSIS only other recourse was to flatten it, which we accomplished with the remaining back pres-   Consideration of all known factors perti- sure " When asked how far from the approach     nent to this accident leads to the conclusion end of Runway 14 the turn on to final was       that there are only two possible explanations started, he replied, "in the neighborhood of    for its occurrence---either there was a sudden 3,000 feet, possibly more, because we were      malfunctioning of the aircraft which rendered traveling at the rate of 125 knots there, and   it uncontrollable at a critical point in the we ended up, I believe, at 800 feet rt          approach, or there was a serious error in Both the captain and the copilot were m         judgment and flying technique Since the substantial agreement that the altitude         physical evidence indicated no malfunctioning when turning on to final was between 400 and    and no malfunctioning was reported by either 500 feet and the air speed was 120 knots,       the captain or the copilot, it appears that light rain was encountered, and the wind-       this first possibility can be eliminated shield wipers were turned on, visibility was    Assuming the situation after turning on to not restricted between the flight and the       final to be as described by the copilot---air airport, and no turbulence was,encountered      speed 120 knots, altitude 400 feet, 1,500 during any portion of the landing approach      feet from the approach end of the runway---a Seven of the ground witnesses were part of      descent of approximately 7,000 feet per the crew of the Cable, a salvage vessel oper-   minute would have been required to put the ating approximately 1,500 feet from the scene   aircraft into the water 800 feet short of of the accident By the nature of their oc-      the runway If we take the captains cupation, these men are well qualified to       description of the situation---air speed 120 judge distances, speeds, and angles Their       knots, altitude 400 feet, 3,000 feet from the testimony was in general agreement that the     approach end of the runway---a descent in ex- aircraft was in an almost continuous de-        cess of 2,200 feet per minute would have been scending turn from the downwind leg until im-   required to put the aircraft into the water pact with the water, and that the bank was      at the point of irrpact These estimates are steepened during the final portion of the       based on a constant air speed of 120 knots turn to line up with the runway Altitude        However, both the captain and the copilot estimates for the approximate point where       stated that there was no reduction of power See our selection of aviatioon documents at RareAviation.com Accident Investigation Reportduring the descent, therefore, if their                              1 The aircraft, crew, and carrier were description of the situation is accepted, the                     properly certificated speed during such a descent would have been                       2 The flight was properly dispatched andconsiderably m excess of 120 knots It is                          was routine until arrival m the vicinity of difficult to reconcile the comparatively mi-                      Kingston nor results of the accident with either of                        3 The ram squall in the Kingston area these rates of descent                                            was local m nature and the visibility and That impact forces were relatively light                          ceiling at the airport were well above mini- is substantiated by the fact that no one was                      mums injured (other than minor scratches and                           4 There was no malfunctioning of thebruises), and by the statements of several                        aircraft or any of its components prior to passengers that they thought a landing had                        impact been made on the airport until they saw water coming into the aircraft This is further                          PROBABLE CAUSE borne out by the fact that many of the pas-                       The Board determines that the probablesengers walked rearward and made their exit                       cause of this accident was the serious error through the rear emergency door, the entire                       m judgment and piloting technique on the passenger compartment remained virtually in-                      part of the co-pilot and the failure of the tact until salvage operations were begun                          captain to recognize the error and take over Evaluation of the physical evidence and                           the controls in sufficient time to take cor- testimony leads to the conclusion that a                          rective action steeply banked turn was being made at a low altitude in an effort to align the aircraft                                   BY THE CIVIL AERONAUTICS BOARD with the runway, and in so doing the right wing tip contacted the water                                                      /$/            DONALD V     NYROP /$/ OSWALD RYAN FINDINGS                                                                          /s/ JOSH LEE Cti the basis of all available evidence,                                          /s/ JOSEPH P. ADAMS the Board finds that                                                              /s/ CHAN GURNEY---39207 INVESTIGATION AND NEARING                        FLIGHT PERSONNEL The Civil Aeronautics Board was notified         Captain John Olsen, age 35, has been em- at I100 EST, September 2, 1951, by the Pan       ployed by PAW A since July 13, 1942 His to- American World Airways of the occurrence of      tal time was 9,666 hours, of which 2,618 were this accident An investigation was inrr.edi-     on Convair 240 type aircraft He held cur- ately initiated m accordance with the pro-       rent AIR certificate No 32742, with single- visions of Section 702 (a)(2) of the Civil       and multi-engine land ratings, 0-6600 hp .Aeronautics Act of 1938, as amended A pub-      His last route check was acconplished on May lic hearing was held in connection with the      5, 6, 7, and 8, 1951, and his last technique investigation at Coral Gables, Florida, on       check on Convair 240 on August 15, 1951 October 11, 1951                                 Copilot George 0 Wright, age 31, held commercial certificate No 40062 with smgle- AIR CARRIER                                      and multi-engine land and instrument ratings His last technique check on Convair 240 was Pan American World Airways, Inc , is a           accomplished June 16, 1951 He was first em- ployed by PAW A from October 14, 1946, New York corporation, having its main offices    through December 31, 1949 After an absence at 135 East 42nd Street, New York City, and      of approximately six months he was reinstated operates as an air carrier under a certifi-      July 13, 1950 His total time as pilot was cate of public convenience and necessity and     2,591 hours, with approximately 1,199 accumu- an air carrier operating certificate issued      lated on Convair 240's pursuant to the Cavil Aeronautics Act of         AIRCRAFT 1938, as amended These certificates author-      The aircraft, a Convair Model CV-240, ize the carrier to engage m air transporta-      N 90662, was manufactured October 13, 1948, tion with respect to persons and property be-    and had a total accumulated time of 4,146 tween various points in the United States and    hours It was equipped with two Pratt & foreign countries, including Kingston,           Whitney Model R-2800-CA-18 engines, with Jamaica                                          Hamilton Standard propellers, Model 23260---39207                                         (I) >? f fy\ vZ*,' ., . See ^W^i^|^^RareAv^ion.W                                                                             .'^r.'^  . .-*. .. *!*..v rLAPPENDIX "A"PAW A                         ACCIDENT AT KINGSTON , JAMA ICASEPTEMBER 2                   1951I N G ST O NJ ' **                                                                                                    Heavy Rain               Area5i?r*- Ir'  Approx. Area ofK..                                                                                                                        Ro in             Squall 4 s*v   \Rs z--- Airplane WreckageCableJamestownPALIS ADOESAIRPORTContrcf TowerCAL            IN          rtCT1000   fOOO                          1000                     4000                     $000w **>---** . .!A>          jFrom PilotManuals.com / RareAviation.com APPENDIX "B DAMAGE CHART PAWA CONVAIR N90662 KINGSTON. JAMAICA SEPTEMBER 2, 1951 SA- 258                                                                                                                                 A  . 1-0026Cl V!L AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: September 23, 1952                                                                                    Released: September 26, 1952PAN AMERICAN WORLD AIRWAYS,                    INC. - SAN JUAN, PUERTO RICO APRIL 11, 1952The AccidentA 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 6I4 passengers, including six infants. Fifty-two passengers lost their lives as a result of this ditching, and the aircraft sank in water approximately 2,000 feet deep and could not be recoveredHistory of the FlightPan American Irtorld Airways' 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                                                                                    9 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 io 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 starbed. 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, 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, wind1/ All times referred to herein are Atlantic                                                             Standard and based on the 24-hour clock. From PilotManuals.com / RareAviation.com east one eight, altimeter two nine nine five. Ill notify your company. The company was notified and upon request, emergency field equipment was alerted. Because the oil pressure of No. J 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 aircrafts altitude was approximately 3$0 feet. When power was increased, the No. U engine oackfired several times; however, immediately following tnese backfires, the engine continued to run m a normal manner. A climbing turn was initiated to a westerly heading, and the captain said that for best climbing conditions he reduced the aircrafts air speed during the turn to 1U5 miles per hour. This reduction in air speed was accomplished by using up elevator. Upon reaching an altitude of about 550 feet, No. U engine again bacKfired 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. h 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. And at 1218, the tower advised the U. S. Coast Guard Rescue Coordination Center at San Juan that the flight was m 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 forward seat in the cabin and fastened his safety belt. At 1220, an Air Force C-U7 flying in the vicinity notified the San Juan tower that a DC-U seemed to be ditching and accordingly was advised to circle the area. Flight J26A 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 m 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. 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 mile and wind from east-southeast, 16 miles per hour.InvestigationProm 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 m 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 m 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 m hand, and both he and the captain checked all the instruments and controls inthe cockpit seeking an answer to the aircraft's continuing loss of air speed and 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,                                                             none of the seats were torn from their fasteningsThree 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 m an openrack 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 m the rear of the aircraft when the second officer returned to the mam 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 in 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 in the pilots compartment and carry it to the main 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. Wile 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. Due 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 caotain 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. 8. 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-h7 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 1$ 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 527 Captain F. Ee Mams, the pilou-m-command of this flight, statea                                                                            that afxer departingthe 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 dean, fne aircraft was returned to the ramp for magneto service, after which tne engine functioned in a normal manner. During uhe 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 in 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 m this position. Captain Aaams 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 mecnamc,                                                                                  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 5^7 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. u gauge and the No. 1 and No. 2 gauges showed that No. h was registering 20-25 pounds low. No entry of this discrepancy was entereu 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, ths 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 wasgoing 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 oirained 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 in the companys 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 m 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 al! times. The assistant chief mechanic did not consider this course of action necessary and according to company policy sent the following message to the companys Miami office: "OXMIA MJMIA OWSJU N88899 #3 ENGINE FEATHER STAGE U 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  MAS JU 1105h0 In effect, this message means that he was changing the right magneto, that he had found aluminum flakes m the sump 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 companys 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, oil 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. Dram 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 pun?) 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 engines 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 m the tank to the full level, and the engine was then min 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 Board's 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 m complete failure of the reduction gear assembly.The six sludge cups from the No. 3 engine propeller reduction gearing were forwarded to Washington, where the contents of these cups were givena spectrographic examination at the U. S. Bureau of Standards. This ex- amination showed that metal particles were concentrated m the upper 1/32- inch 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- xnch layer had lead as its major metallic constituent aAs 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 Bum was employed by Pan American World Airways as a co-pilot September 9, 1942, and checked out as co-pilot on DC-4 aircraft June 27, 1946 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 consisted his ground school training and 18 hours of flight training on DC-4 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-U 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 m 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, 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 surrounaxng 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 in 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 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, 6 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 thetwo 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*                                         jD an emergency such as this, where the maximum altitude involved was only 550 fee                                                 t, it would seem that good flying technique would not permit a loss of                                                 ,ir speed by maintaining a continuous nose high attitudeThis                                           could well have meant tn difference between maintaining level flight and                                        loosing altitude.The attendants were not advised                                            in sufficient time that the aircraft was to be ditched for them to adequately prepare the passengers for awater 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                  mean 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 thislocation 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.The mechanics at San Juan wno performed the service on the No. 3 engine and changed this engines nose section said that all work doneby them was performed as prescribed m the companys Maintenance Manual The assistant chief mechanic, however, did not consider it necessary to change the engine, although 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                             engine} however, it did indxCAte that some part or parts of the engine had failed. To determine Lhe extent of this failure, the engine should have been further disassembled. This was not done. Instead, a nose section was installed desmte considerable evidence of metal particles in 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 engines propeller reduction gearing definitely showed particles of metals other than aluminum. The top 1/32-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 in the top 1/32-mch of sludge indicated that a progressive failure was occurring. The ab^ve reasoning is in accord with the observed wear pattern on the propeller reduction pinions and drive gear. The eviaence 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 UO, Ul, li2 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 Boards 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 in 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. FindingsOn                                   the basis of all available                          evidence the Board finds that:The carrier, the aircraft                       and the crew were properly certificatedWeather was not a factor m this accidentThe companys maintenance department at San Juan should have been J  alerted         to a dangerous condition when metal particles were found m the nose section         of No. 3 engine.Pan Americans 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 changed5.         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.7. The captain demonstrated questionable flying technique under the existing conditions.Probable CauseThe Board determines that the probable cause of this accident was (a) the companys 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 in 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,                                                                                          progressive loss of air speed and the settling of the aircraft at too low an                                                                                         altitude to effect recovery.BY THE CIVIL AERONAUTICS BOARI/s/              DONALD W. NYR0P/s/ OSWALD RYAN /s/ JOSH LEE/s/ JOSEPH P. ADAMS/s/ CHAN GURNEYSee our selection of aviatioon documents at RareAviation.com SUPPLEMENTAL DATA The Miami office of the Civil Aeronautics Board was notified of this accident by Pan American World Airways m Miami at approximately 113$ EST April 11, 1952. 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 public hearing was ordered by the Board, and was held in the Public Amusement and Park Administration Building, Ponce De Leon Avenue, Parada 3, San Juan, Puerto Rico, on May $, 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, was employed by Pan American World Airways September 9, 19112. 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 m DC-U equipment. He was qualified to fly as captain in DC-li aircraft January 11, 1952. He nad a total of 208 hours as pilot-in-command of DC-U aircraft prior to the accident. His last instrument and equipment check was accomplished January 11, 1952 and his last route check was on January 13, 1952. Captain Burn 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 ?08 were m DC-h 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 3t, 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 5U were in DC-li 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 Li, 19U6. Steward R. Torres was emoloyed by Pan American World Airways on July 2, 1951. The AircraftN88899, a Douglas DC-U, was owned and operated by Pan American World Airways and was currently certificated by Civil Aeronautics Administration. It had a total of 2O,835> flying hours, of which 1,J>1U were accumulated since overhaul, and was equipped with Pratt & Whitney R-2000 engines and Hamilton Standard 23E-5O propellers.ii  SA- 264                                                                                                  File No. 1-0080 CIVIL AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: June 23, 1953                                                              Released: June 26, 1953PAN AMERICAN WORLD AIRWAYS, INC., - NEAR CAROLINA, BRAZIL, APRIL 29, 1952The AccidentAt approximately 0740                                                       1/ GMT , April 29, 1952, a Pan American World Air- ways' Boeing 377 aircraft,                                                  N* 1039V, being operated as Fli^it 202 between Buenos Aires, Argentina, and New York, New York, crashed in the dense Bra- zilian jungle about 887 nautical miles north-northwest of Rio de Janeiro, Brazil, its last point of departure. All 50 persons aboard, consisting of Hl passengers and a crew of nine, lost their lives, and the aircraft was con^letely demolishedHistory of the Fligat Flight 202 originated at Buenos Aires, destination New York, with en route stops scheduled at Montevideo, Uruguay; Rio de Janeiro, Brazil, and Port of Spain, Trinidad. The fli^it of April 28, 1952, departed the Buenos Aires ramp at 1826, returning at 1834 for maintenance, and at 1848 again left the ramp, becoming airborne at 1852 After a scheduled stop at Monte- video the fli^it arrived at Rio de Janeiro at 0105, April 29, 1952 Here a routine crew change was effected, and at 0217 the flight departed with a new crew consisting of Captain Albert Grossarth, First Officer L A Penn, Jr , Navigator John T Powell, Fligit Engineer Paul L Stilphen, Radio Operator Leroy R Holtzclaw, Stewards Anthony L Urda, Anthony Nasco, and Julio Hansen, and Stewardess Patricia Monaghan.The aircraft was cleared for an off-airways direct route fr                                           JM        Rio de Janeiro to Port of Spain, to cruise from Rio to Barreiras check point at 12,500 feet altitude, from there to Santarem at 14,500 feet, and from Santarem to Port of Spain at 18,500 feet The estimated flight time at standard cruise was 10 hours and 30 minutes, with a fuel requirement of 7,296 gallons The estimated flight time on long-range cruise was 11 hours and seven minutes The actual fuel aboard at departure was 7/400 gallons The taie-off weight was approximately 3^550 pounds below the maximum allow- able wei^it.1/ All times referred to herein are Greenwich Mean and based on the 24-hour clock. All times referred to after arrival at Rio de Janeiro nay be converted to local time by subtracting three hours On departing the ramp the aircraft was observed to taxi to Runway 32 and stop on the taxi strip headed southwesterly, where the engines were heard to run up Without any noticeable malfunctioning. From this position, at 0230, the flight advised that it was returning to the ra nance. However, the aircraft was observed shortly thereafter to taxi south- eastward to the runway's end, turn to a northeasterly heading where it re- mained for approximately 10 minutes, following which it turned northwest and took off.A message from the flight at 0306 advised that its take-off time was 0243, estimating abeam of Palmira, Brazil, at 0326. It next reported abeamof Palmira at O325, estimating abeam of Bello Horizonte, Brazil, at 0354- It reported abeam of Bello Horizonte at 0357 and estimated abeam of Montes Claros, Brazil, at 0444. At 0448 the Porto Alegre, Brazil radio station relayed a message to Rio stating that the flight reported abeam of Montes Claros at 0445, estimating abeam of Barreiras, Brazil, at 0610. All mes- sages stated the flight was flying under VFR conditions, off airways, at 12,500 feet altitude.At 0616 the Cayenne, French Guiana, radio station relayed to Belei                                                                                11 Brazil, hence to the Rio station, a message from the flight, reporting abeam of Barreiras at 0615, flying at 14,500 feet under VFR conditions and estimating abeam of Carolina, Brazil, at 0745- Ohis was the last known message from the flight.When the flight failed to report at its Carolina check point or arrive at Port of Spain, its next scheduled stop, a missing-aircraft procedure wasimmediately initiated. On May 1, 1952, the wrecked aircraft was spotted from the air and plotted by the United States Air Force Search and Rescue Unit as latitude 9 45 3^" south, longitude 50                                                                  47' 18" west. Obis posi- tion placed the wreckage approximately on course                                                                 282 nautical miles north- northwest of the Barreiras abeam check point, 36                                                                     nautical miles south- southeast of the Carolina abeam check point, and                                                                approximately 887 nautical miles rrom Rio, the point of departure.Ihe forecasts and. verbal briefing furnished.                                        the crew prior to depar- ture Indicated a partly cloudy to cloudy condition from Rio de Janeiro to six degrees south latitude, consisting of two layers, one at about 2600 feet and the other at 14,800 feet. From this point to the northern border of Brazil, scattered cumulo-nimbus with showers were expected and cloudy thence to Trinidad. Winds aloft at cruising level were expected to be westerly about 25 knots from Rio to Montes Claros, then northerly about 18 knots to six degrees south and northeasterly 8-13 knots to Trinidad. Moderate tur- bulence was expected north of six degrees southInvestigationihe Civil Aeronautics Board was notified at 1800, May 1, 1952, that the wreckage had been located in a dense jungle in Para State, Brazil. Upon re- ceipt of notification, a Civil Aeronautics Board investigator was dispatched immediately to Belem, Brazil, to act as the accredited United States repre- sentative He was also authorized to act as investigator-in-charge to whatever extent the Brazilian Government permitted the Board's participationm the investigation of the accident The investigator arrived at Belem on May 3; 1952, and immediately contacted the U S Consul where it was learned that the Brazilian Government's investigation of the accident was being con- ducted by Brigadeiro Rodrigues Coelho, First Air Zone Commander, Forcas Aereas Brasaileiras (FAB) The CAB status in the investigation could not be determined at this tuneThe investigator was briefed concerning the air search operation which had been conducted by Flight C, First Air Rescue Squadron, USAF, Ramey Air Force Base, Puerto Rico. Aerial photographs taken during this operation indicated that the wreckage was scattered over approximately a one-mile area which was divided into two se             Silk             snts.            one containing large sections of the aircraft believed to be the fuselage and the right wing, and the other con- taining the left wing and numerous smaller pieces When it was determined there were no survivors and that an attempt to reach the scene of the acci- dent by parachute teams would be impracticable because of the dense jungle, the USAF Air Search Unit returned to its base Observations made by all air search and survey parties indicated that the only practical way to reach the scene would be to plan an expedition using a land plane airlaft from Belem to an airstrip at Araguacema, 523 miles south of Belem From this point an amphibian airlift could be used to Lago Grande, a point 85 miles south of Araguacema on the Araguaia River With a base camp established at Lago Grande, a foot trail could then be cut from Lago Grande to the wreckage, a distance of approximately 35 miles, 26 miles of which were through dense jungle This plan was chosen because the Araguacema airstrip was tne closest land plane landing area to the wreckage, and Lago Grande, a village of four mud huts, was located at a point on this river which was capable of accommo- dating large amphibian aircraft at this season The village of Lago Grande is located in a jungle area bordering the Araguaia River 'This river has a 60-70 foot rise during the rainy season, which makes the use of the PBY am- phibian possibleBrigadeiro Rodrigues Coelho was unable to attend a meeting of inter- ested parties arranged for the following day, May 4, at which time tenta- tive plans for the proposed expedition to the scene of the accident were to be discussed It had been hoped that since the investigating group were there by rhe pleasure of the Brazilian government, the Brigadeiro would at that time clarify the status of the group and make known to them the extent of the Board's participation in the investigation There were present at this meeting, representatives of the Civil Aeronautics Board, Civil Aero- nautics Administration, Pan American World Airways, United States Air Force, Panair do Brasil and Pratt and Whitney Aircraft Division The use of a heli- copter as a means of transporting personnel to the scene of the accident was discussed It was agreed that its use was practicable, providing safe opera- ting clearing were prepared both at the Lago Grande base camp and m the vicinity of the wreckage It was further agreed that it was necessary to improve the Araguacema landing strip to acc                                                late a transport aircraft which could deliver to that                                        point a dismantled, helicopter From here a helicopter could proceed to                                         the Lago Grande base camp, which was within Itsfuel range.It was learned through                         the United States Consul that the Brigadeiro had assigned Major Carlos Miranda Correa, of the FAB, to handle the investi gat ion for the Brazilian Government, and at a meeting with Major Correa at the United States Consulate on May 6 the CAB representative was invited to participate in the investigation in accordance with the International Civil Aviation Organization (ICAO) agreement.The plan of action discussed at                                                                    the May U meeting was agreed upon, which was predicated upon the cutting of a                                                               jungle trail, using natives led by PanAmerican employees who were familiar                                                               with the Jungle, from the Lago Grande base to the scene of the accidentA request was then forwarded to                                               Washington to obtain the services of a USAF helicopter, with crew, and an aircraft to transport the helicopter, to gether with the necessary jungle survival equipment, to the Araguacema land ing strip.On May 7 the Brazilian Boundary Commission and the Indian Protective Agencies were visited to obtain information on the conditions to be expected in the jungle and the equipment needed During this discussion officials of these agencies stated that friendly Carajai and Tapirape Indians would be found in the Lago Grande area but that th                                                                                                      wreckage was located in an area known to be occupied by hostile Ciapos Indian tribes.                                                                                                          Ihey further advised that any party going into this area should be well-armed                                                                                                           should not attemptany contact with the Ciapos tribe; should remain in a group and not become isolated; should fire upon Indians if they were encountered; should equip themselves with suitable clothing to protect against jungle briars, thorns, and vines; and that protection should be provided against wild boars, black leopards, jaguars, and snakes of the boa constrictor and viper species. They further stated that the area surrounding the wreckage had never been explored and, as far as known, there was no habitation west of the Araguaia RiverOn May 8 Major Correa accepted the services of the three CAB personnel present, two of whom had just arrived, as chairman of working groups to be set up to establish proper division of work and responsibility Major Correa then named members of the structures, powerplant, and investigating groups, realizing that some re-arranging of the groups might become necessary depend- ing upon conditions met It was further agreed that the technical personnel would remain in Belem until the helicopter arrived and the base camp at Lago Grande was readyIhe base camp was established at Lago Grande and arrangements made to clear the approach path to the Araguacema landing strip to permit the USAFtxansport aircraft to deliver the helicopter While this was being accomp- lished, a message was received at Belem from the Lago Grande base camp stat- ing that, while flying over the wreckage area, the crew of a supply flight observed parachutes in the tops of trees and the presence of persons in a partial clearing located about four air miles from the main wreckage The following day Brazilian newspapers reported that the parachutists dropped into the clearing were a group of civilians backed by Ademar de Barros, former Governor of Sao Paulo State It was later learned that after the clearing was sufficiently enlarged, Linos de Matos, a leader of the group and deputy to the former Governor, had been transported to the clearing in a Brazilian             two-place helicopterOn May                  11 a USAF C-82 Packet aircraft arrived, at Belem, carrying the helicopter,             a Sikorsky Model S-51 In addition to its flight crew., it also carried a C-82 mechanic                         two helicopter mechanics, a five-man jungle team, and eight jungle survival kits                                                   Additional jungle equipment and a doctor with medical supplies were furnished by PAWA-On the morning of May 12 the C-82 Packet departed Belem for the Ara- guacema airstrip, followed by a Pan American C-46 carrying the helicopter crew, jungle team, mechanics, and CAA-CAB personnel. Upon arrival at Ara- guacema The C-46 passengers continued on to Lago Grande in a Panair do Brasil Airways PBY amphibian, returning to Araguacema the same day after inspecting the helicopter clearing there and flying over the wreckage tc select a possible helicopter site nearbyEvery effort was made to expedite assembly of the helicopter on its arrival at Araguacema to enable this expedition to reach the scene asquickly as possible, it being felt that unknown persons in the wreckage area might disturb or destroy valuable evidence rBie Brazilian authori- ties were unable to furnish any information concerning these persons other Than that contained in the newspapers. ihe advance party which had arrived at Lago Grande to set up the base camp had prepared a canvas-covered shelter, had rented one of the mud huts and converted it into a storeroom, first-aid station, radio station, and kitchen, and had cleared a landing area approximately 200 feet in diameter in the adjacent jungle for the use of the helicopter On May 13 the assembly of the helicopter was completed, and it was flown to the Lago Grande base, arriving late that afternoon.In addition to preparing the base camp and helicopter landing area at Lago Grande, two alternating ground parties, including numerous newsmen and led by Pan American employees familiar with the jungle, had cut a path from Lago Grande to within approximately 10 miles of the wreckage. These ground parties were guided through the jungle by the crew of the PBY aircraft, who upon observing smoke bomb signals, made daily food drops and noted compass courses to the wreckage on tags attached to the drop sacks Along the 16 miles of trail cut toward the wreckage, only two widely separated water holes were found, at which points camps were constructedSince the ground parties were still approximately 10 miles away from the wreckage, a conference was held in Lago Grande, attended by representatives of all, interested, parties, -which included, the two helicopter pilots and Lieutenant Ferreira representing Major Correa, to expedite the movement ofthe investigating groups to the scene It was decided that the use of the helicopter from the Lago Grande clearing to the one utilized by the para- chutists would best accomplish this purpose. From this point, working groups could be moved quickly by helicopter to the proposed clearing near the wreckage, a distance of approximately four milesA factor also considered at this time was the establishment of Bra- zilian Government security over the wreckage to prevent its possible dis turbance                     For this reason Lieutenant Ferreira and a representative of Pan American were the first to be flown into the clearing,                                                                  On subsequent flights Major Correa, a Para State Police officer, and an FAB medical of- ficer were transported to the clearing to complete the Brazilian Govern- ment representation, and by May 15 all members of the powerplant and struc-tures groups and an operations observer had been transported to the clearingHie previously mentioned PBY amphibian, and later an FAB PBY amphibian brought to Lago Grande for the use of Major Correa, alternated in providing air surveillance over the helicopter and in dropping food supplies Radio communication from the Lago Grande camp was maintained with the helicopter, the amphibian, and the advance camp now established at the parachutists 1 clearing.During the seven helicopter flights required to transport the total party of ih- to the clearing, a Brazilian Bell helicopter and two lightplanes, operating from a high point in the marsh area approximately seven miles from Lago Grande, could be seen from time to time flying over the clearingOn May 15, following the seventh and last trip necessary to bring                                                                         t personnel into the clearing, the helicopter developed serious vibration in the tail area Inspection revealed that the entire tail cone had become distorted, probably the result of unloading operations at Araguacema with- out the aid of lifting lugs, and the forward bearing of the tail rotor drive was overheating badly Ihis difficulty was beyond correction by the me chan- ics under the existing conditions, and the USAF was unable to furnish the replacement of the tail cone at that time, neither was it in a position to furnish a substitute helicopter to continue the operations.At about this time one of the alternate groups cutting the trail from Lago Grande to the wreckage was ordered to return to Lago Grande, and the remaining group was instructed to discontinue cutting the trail and proceed to the wreckage singly in the most expeditious manner possible. Ihis action presented a new problem, since it did not permit the trail to the wreckage to be completed and, therefore                                     in the event it was necessary for the in- vestigating group to walk out through the jungle they had no way of locating that portion of the trail which had been finished and the very necessary water holes along its route. The pilots, after evaluating the situation, pointed, out that possibly the helicopter, before the bearing failed completely, could make the seven trips into the clearing necessary to evacuate the group of 1U -when they were ready to return, but it would, except in an emergency, be necessary to re- strict its operation to that purpose only.                                                              This situation was made known to the group at the parachutists 1 clearing by means of portable radio eequip- ment operated by Mr                         Scott Magness     3            a Civil Aeronautics Administration Avia- tion Safety AdvisorWith the problems now confronting the investigating group, it was de- cided to continue as much of the investigation as possible under the circum-stances, using the clearing, where an adequate water supply was available, as a base, having in mind the possibility of establishing another camp at the wreckage providing an adequate water supply could be found in the im- mediate area                                Fr         the base camp the aircraft wreckage lay to the north- west over the rocky and rugged Tomanacu Mountain Range, a distance of about four air milesOn the afternoon of the 15th a representative group of all interested parties, each carrying a canteen of water and a small supply of USAF "C" rations, left camp in an attempt to reach the scene of the accident A very circuitous route led the party over such rough and rugged terrain that at times the use of guide ropes was necessary to make any progress All but eigit of the official party were defeated by the terrain and tropical heat, and returned                             to the base ca               Those who returned                                    included the FAB medical officer, who suffered a heart attack, and the Para                                                                          State Police official, who was seriously injured by a fall.By the time these members turned back, it was evident that the trip would be overnight en route and there was a possibility of water shortage They were, therefore, instructed to notify the base camp at Lago Grande by radio that the PBY crew, which accomplished daily food drops to the group, should look for smoke bomb signals at the wreckage which would indicate the need for an emergency helicopter flight to lower water to the group, as water could not be successfully dropped from the PBYIt later developed that the distance between the base camp and the wreckage by the shortest practical route was approximately seven miles An overnight camp was established on the trail, and on the following day, May 16, the investigating party was met on the trail by six members of the parachu- tists group, including their leader, Linos de Matos This group, now out of water, Joined the official party The official investigating group which finally reached the main wreck- age area on May 16 was now reduced to eight persons - two representing the Brazilian Government, two, Pan American World Airways, one, Civil Aeronautics Board, one, Flight Engineers International Association; one, Air Line Pilots Association, and one, United Aircraft Service Corporation. It had been determined by aerial observations made by the First Air-Sea Rescue Squadron, Alb rook Field, Panama, and by photographs prepared by the Strategic Air Command, Ramey Field, Puerto Rico, that portions of the wrecked aircraft lay in four separate areas of the jungle. Upon arrivalof the investigating party at the area containing the main wreckage, it was apparent that other persons had preceded them, as was evidenced by disturbance noted in portions of the wreckage On May 17, 1952, this already-enlarged party was joined by the ground party, which had been in- structed to abandon cutting the trail from Lago Grande to the wreckage and had proceeded singly to the scene Lis group of approximately 25 persons, including numerous newspapermen, were also out of water. During the first night spent at the wreckage, the water in                                                    the canteens of official group disappeared.This area contained what remained of                                                                  the aircraft fuselage from, the cockpit aft to the pressure bulkhead, the                                                            right wing, Kos. 3 and U engines together with their respective propellers, a                                                             id the aircraft's landing gear It was deemed impracticable at the time to attempt to reach the other wreck- age areas due to the lack of trails throu^i the jungle and to the absence of supplies, communications, and protections                                                                  On the following day, May 17, emergency smoke bomb signals were sent up                                                            indicating the need of water, whichsignals were observed by the PBY crew.With the emergency helicopter flight                                                 now necessary} it was decided, that this trip would be the first of the seven                                            evacuation trips required, and. the helicopter would be diverted over the wreckage area to lower water cans while enroute from Lago Grande to the parachutists1 clearing Lowering the water cans to the main wreckage, however, proved to be only partially successful due to the 100-115 foot high trees and the unstable air, and it was consider- ed too dangerous for further attemptsIt was necessary at this, time to divert the efforts of some of the in- vestigating party to the burying of bodies, gathering of personal effects                                                                                  > and making positive identification of the aircraft                                                                         la.    base of the work was accomplished under the supervision of Major C M Correa, FA                                                                                     and Mr. H W. Toomey, PAWA, Latin American Division                                                        The first task of the investiga- ting group was to locate and identify as many of the larger pieces of wreck- age in the area as possible, in order that a record of their distribution and condition could be made for future referenceQhe wreckage was located, at an altitude of approximately 1300 feet on the side of the Tomanacu Mountain Range and was found lying in an inverted position on an approximate heading of 90 degrees.Hie wreckage area consisted of a large burned-out hole in the jungle approximately 100 feet in diameter Indications were that this portion of the aircraft had made a nearly vertical descent while in a horizontal atti- tude; this was evidenced by the condition of the surrounding trees, all of which had been damaged from directly overhead. One such tree approximately four Inches in diameter had vertically pierced No. t engine cowling.Further observations disclosed extreme disintegration of the aircraft, accompanied by fire which followed impact and had probably continued for many hours. The heat of this fire melted many pieces of the aluminum alloy structure, which resolidified into unrecognizable globules and masses of metal. Many structural parts which retained identifiable shape had their fractured edges melted or burned away, making study of them impossible.On May 18 all Pan American World Airways personnel were ordered to return to the base camp. Government personnel were advised that if theydesired to remain and continue the investigation, daily drops of "C" ra- tions would be provided. However, under the existing conditions and with no water supply available, investigation at the main wreckage was discon- tinued and the official party returned to the base campThe evacuation of the official party from the parachutists camp began on the 18th. During the first two evacuation flights, the bearing condition on the helicopter became progressively worse. This, plus the necessity of HIHI                               idiate evacuation of one of the newspapermen stricken with appendicitis and a PAWA employee with an injured foot, made an eighth trip necessary to complete the evacuation. This condition influenced the helicopter pilots to abandon their safety measure of riding together in case of forced landing. This arrangement provided an additional seat for evacuation purposes.When it became apparent that the United States Air Force helicopter could not long continue the evacuation flimits, Mr. de Matos, leader of the Brazilian parachutists group, called to the Investigating parties' attention the fact that he and his men would then have no means of leaving the clear- ing. It was suggested that the Brazilian helicopter, which reportedly had brougit de Matos into the clearing, assist in the evacuation This, however, was said to be impracticable, as at this altitude, this machine could not lift a passenger in addition to the pilot. It was therefore decided that the United States Air Force helicopter on return flints, would bring in a power saw and the necessary axes and machetes with which the remaining para- chutists and newspapermen could improve the clearing sufficiently to permit the operation f their light plane which was based at a point near Lago Grande, power saw and small tools necessary to prepare the landing strip were de- livered; however, the sixth and last evacuation trip, on May 18, found CAA Adviser Magneae and FAB Major Correa still at the clearing.On May 19, Brigadeiro Coelho and Colonel Proenca, FAB, arrived at Lago Grande with a contingent of FAB enlisted men and took over the base camp as well as the responsibility of evacuating the two remaining members of the investigating group still at the parachutists' clearing. In addition, all Americans were ordered to return to Belem with the assurance that the two ^oup members, upon being brought out of the Jungle, would i                              ?dlately be flown to Belem in the FAB PBY aircraft. On May 21, while waiting the arrival of Mr. Magness and Major Correa, a meeting was held to discuss the possibili-ties of continuing the on-the-spot investigation. Die consensus was that any further investigation at the scene would require a carefully organized and much better equipped expedition and that such a recommendation would be presented, to the Civil Aeronautics Board.. There was some question whether further investigation at the scene would, be possible since the U. S. Consuladvised, that the Brigadeiro was opposed to such an undertaking. On Way 23/ information was received that a Brazilian privately-owned light plane, in landing on the newly prepared landing strip at the parachutists' clearing, had been involved in an accident. On May 24, however, replacement parts were dropped from FAB aircraft, repairs were made after which Major Correa and CAA Advisor Magness, the last men to be evacuated, were flown out ar- riving at Belem on May 28. The USAF, in the meanwhile, had at the request of the Board photographed -Hie entire wreckage area during a nonstop round- trip flight from Ramey Field, Puerto Rico, and on May 31 all members of the official group were released pending possible reactivation of the invest!- gation at the scene.The following two and one-half months were spent in obtaining authori- zation from the Brazilian Government for a second expedition and in the ar- ranging and equipping of this expedition, which was to be composed of men qualified to conduct a thorough technical examination of the wreckage thus far located and to continue thorough air and ground search for missing com- ponents .Brigadeiro Coelho, FAB, having completed his investigation, had released the wreckage to Brigadeiro Raimundo Aboim, Director Aeronautica Civil (DAC), to whom all matters concerning the Board's expedition were now to be refer- red. In the meanwhile, Brigadeiro Aboim had prepared a landing strip suit- able for an airlift near Lago Grande, since the Araguaia River would not accommodate the PBY amphibian operation during the dry season,                                                                                    addition to facilitate removal of all bodies and personal effects                                                                       a 35-mile Jeep trail had been cut through the Jungle from the landing strip to the main wreckage.                    After this had been accomplished,                                the Civil Aeronautics Board on August 15 received authorization from Brigadeiro Aboim                                                                to proceed with its expedition, and on the same day the FAB broke camp at Lago Grande. All their personnel and equipment were removed, with the exception of Lieutenant Bonno, who had been assigned by the First Air Zone, FAB, to act at observer during the Board's investigation, and the radio station with its two operators.By August 23 the CAB base camp at Lago Grande and the advanced camp near the wreckage had been completed, using a PAWA C-16 aircraft for trans- portation of personnel, equipment, camp supplies, firearms, and Jeeps with trailers from Belem to the Lago Grande airstrip. The personnel of the in- vestigating groups and official observers were selected and furnished all available information concerning wild animals, hostile Indians, insects, and diseases likely to be encountered in the jungle, and of the expected average Jungle temperature of 100 degrees during the day and approximately 15 degrees at night.During the two following days, all observers and members of the power plant and structure investigating groups were transported by jeep and trailer to the advance camp over the 35-ile trail. The Jungle through which the trail passed was actively on fire Although the fire was confined mainly to dead vegetation on the ground and spread in a slow, smouldering manner, it attacked the bases of many old and deteriorating trees with the result that progress along the trail was punctuated by numerous loud reports of large trees crashing to the ground. This slow burning and the falling of trees continued until the beginning of the rainy season The necessity of sawing a way through or hacking a way around newly fallen trees was the major cause of some Jeep trips extending from the normal 5i or 6 hours to as long as 12^ hours.                                                                                     The work of both groups continued daily, from August 24                                                                             through September 10, by which time the rainy season was well advanced,                                                                            making the immediate evacuation of all personnel and equipmentnecessary                                                                            During this same period a continuous ground and air search was conducted                                                                            in an effort to locate missing aircraft components This search consisted                                                                         of 18 hours 45 minutes of flying time over the area and 3,002 man hours by ground parties working from the advance camp,                                                                                        The result was only partially successful in that the engine and propeller which had been                                                                                    1 n fit al - led in the No. 2 position were not located.Examination of the WreckageThe men assigned to the structures and power plant groups began                                                                                         their operations immediately upon their arrival at the scene on August 24                                                                                         These groups, being fully aware that al 1 work in connection with the examination of the aircraft wreckage would of necessity have to terminate as soon as the rainy season got underway, scheduled examination of components in the order of the importance of the information they expected to obtain. As a result of air and ground search, it was found that parts of the wrecked airplane were scattered over an irregularly shaped jungle area whose major dimension was approximately 4,000 feet 2/In evaluating the fire damage to the various components, consideration was given to the fact that the wreckage at the main site had received heavy- damage from the fire which immediately followed impact, as well as from the application by the Brazilians of flame throwers to the wreckage, for sani- tary reasons, following the removal of the bodies and personal effects of the passengers. In addition, a forest fire had swept over the entire wreck- age area                            a short time before the arrival of the investigating groupThe                                 parts at the main wreckage site consisted roughly of the fuselage from the                            nose back to and including the dorsal fin, the complete landing 3 and 4 nacelles c gear, the right wing with Nos 3 and. 4 nacelles complete with engines and propellers, that portion of the left wing from the fuselage outward to a point slightly outboard of the No. 2 nacelle, and the                                                                                  No 2 nacelle minus the No 2 engine, engine cowling, and propeller                                                                           The outboard portion of the left wing was found approximately 2,300 feet from and on a bearing of 318 degrees from the main wreckage, complete with No 1 nacelle, engine,2/ See Appendix A engine cowling, propeller, aileron, and outer portion of the left flap. Examination revealed that this portion of the wing had struck the ground, inboard end first, at an angle approximately 60 degrees from horizontal.The tail assembly wreckage consisted of the vertical fin, right ele vator, horizontal stabilizer from the right tip to approximately th                                                                                                         mid span of the left stabilizer, and the aft end of t                                                                                                                  his piece of wreckage was found approximately 2,500 feet fr                                                                                          : and on a bearing of 50 degrees from the left wing wreckage.                                                                               At different points close by were found the                                       rudder and approximately the inboard third of the left elevator.Most           of the remaining structural parts of The aircraft were found within an           area encompassed by a circle of approximately a 350-foot radius. From the center of this circle,                                                                  the distance to the tail assembly wreckage was approximately 1,000 feet on a bearing of roughly 340 degrees,                                                                                                       Theseparts included the outer portion of the left horizontal stabilizer,                                                                                                        the middle portion of the left elevator, two inboard pieces of the left flap, the right-hand nose wheel well door, and the tip section of the right aile- ron. .tSince these pieces from different extremeties of the aircraft do not vary too greatly in density, their close grouping indicates that the dis- integration of the aircraftfs structure occurred                                                                                           a very short intervalof time.The wing structure at the main wreckage site was found to be severely disintegrated by the impact force and was extensively consumed by fire fol lowing inpact. However, from an examination of the debris it was                                                                                                                '4 that the basic wing structure was                                                                           act from the n^it wing tip through the center section to the outboard edge of No                                                                               2 nacelle until the fuselage towhich it was attached struck the ground.The most outboard                      portion of the left front spar lower chord found at the main wreckage site                      extended from Station 157 to 202. The                                                fracture at the outboard end was a                      tension failure, which occurred at the                                               second, large bolt from the outboard                      end of the scarf splice in this area.                                                There was some evidence of heat                                                         on parts of this section of spar chord which                                       passes through the No. 2 engine                                                           nacelle. However, since the evidence indicates application of heat of equal                                                           intensity on both fractured and nonfractured surfaces                                              > is apparent that                                                           it resulted from fire following impact with the                                          ground.The most outboard portion of the left rear spar lower chord                                                                                                         found, atthe main wreckage site extended from Station 90 to Station 224.                                                                                                      The fractore at Station 224 was a tension failure with a slight indication of up- ward bending. The fracture occurred at the third bolt from the inboard end of the scarf splice in this areaThe most outboard portion of the left wing lower surface found at the main wreckage site was a section of the lower surface panel from Station 221 inboard approximately half-way to the fuselage The fractures of the skin and stringers at the outboard end were tension failures The fractures extended from the rear spar at Station 221 directly forward through Stiff- ener No 3 From this point it extended inboard and forward through the wheel well doubler at approximately Station 200 and Stiffener No 6The spar rear chords found at the site of the left wing wreckage had been driven into the ground approximately three feet by the impact forces Interference with a boulder and the ground stripped off all of the surround- ing structure lhe impact forces and fire after Impact severely disintegra- ted and melted most of the structure from the inboard end out to Station 510 From this Station to the tip, the panel was intact except for several in- stances of impact damage One of these was inward deformation of the wing tip directly aft of the position li$it, which together with its plexiglass former was missing Specimens of white deposits on the skin in this area were removed for laboratory analysislhe sections of spar lower chords which speared into the ground mated with the outboard extremities of the spar chords found at the main wreckage site indicating definitely the spanwise station of the wing separation in flight The inboard portions of these sections of spar chord which were buried in the ground showed no evidence of heat Due to the extreme shatter- ing on impact and the melting which occurred in the fire after impact, no portion of the nose section or upper and lower surfaces just outboard of the wing separation was identified for further study of the separationFuselagelhe fuselage wreckage consisted of m                   Ilf.     srous pieces, larger at the fore and aft ends than in the center portion, generally arranged in an inverted position, squashed flat, and with the longitudinal spacing correspondingroughly to the original length Most sections had evidence of moderate to severe burning after impact                               much of the metal in the center portion of the fuselage having been meltedAn attempt was made to examine the fuselage structure near the plane of the inboard propellers for indications of propeller cuts However, dueto the extremely severe disintegration and melting in this part of the fuse- lage, only two small pieces of structure with portions of the ice striker plates attached were identified There was no indication of propeller cuts on either piece, however, due to the small coverage, the findings are in- conclusive lhe main entry door was found with all bayonets extended and the inside door handle m a horizontal positionCockpit instruments were so severely                              shattered that no significant readings                 could be obtainedThe dorsal fin was found at the main wreckage site, severely torn and mangled There was a large trough-shaped depression in the leading edge approximately two feet below the tip The depression was approximately one foot wide and five inches deep, with the trough running from upper right to lower left and aft A film of oil was noted                                            on the left side of the dorsalfin and on the most rearward portions of the                                          skin from the left side of the fuselageThe only portion of the nose wheel well                                    left door identified was a small fragment attached to a piece of fuselage structure by means of the rear hinge The edges of this fragment were curled inward and the fragment showed no evidence of twisting deformation The ri^it door was found intact with little evidence of distortion, other than that the front bulkhead was forced slightly rearward by impact with the groundTail AssemblyAn examination of the tail assembly wreckage indicated that the fin and the right elevator were not severely damaged prior to impact with the groundThe upper surface of the right stabilizer was noticeably wrinkled A small hole was punched through the upper skin of the right stabilizer and there was a tear in the upper fabric of the right elevator                                                                       The left side of the fin also was streaked with a                             film of oilExamination of the left                                  stabilizer revealed that                                       it had failed m flight along an irregular chordwise                             line near Station 145                         as               the result of an ex- cessive upward load A hole                               was also found in                    the      upper skin surface justforward of the rear spar, beginning at Station 122                                                     and increasing in width to about six inches as it extended outboard This                                                       hole had been made by some zinc chromate painted object entering from above                                                       However, the skin adjacent to the hole also bore gray smears similar in appearance to paint                                                                        There were no indications of impact damage anywhere along the stabilizer leading edge, and the lower surface was also covered with a film of oilThe left elevator had separated into several pieces in flight Exami- nation of the inboard and middle pieces indicated upward bending consistent with and apparently resulting from the stabilizer failure The remaining portion of the elevator was not foundThe rudder was found approximately 250 feet from the tail assembly wreckage Examination of marks on the vertical fin indicated that the rudder had not separated from the fin                                    until after the tail assembly had. separated, from the fuselage Streaks of                                      oil film were also observed, on the left side of the rudderFlight Control SystemsExamination of the flight                              control systems indicated damage consistent with the separation of the left wing and fuselage in flight and with thebreakup and burning of the structure following impact with the ground In addition, the control cables running through the fuselage were found to have been hacked, sheared, and chopped into many pieces varying from three to six feet m length subsequent to the accident This condition very likely re- sulted from the Brazilians finding it necessary to move portions of the wreckage to facilitate the removal of bodies and personal effects However, no indications were found of control systems 1 connections having failed in service All four of the wing flap actuating screws were m positions which correspond with flap extension of approximately three to four degreesPower Plants Ihis aircraft was powered by four Pratt and Whitney, Model R436O-TSB3Gengines equipped with Hamilton Standard Model 2h-26O-43 propellersNo 1 engine was found with the left wing which had separated from the aircraft at a point just outboard of the No 2 engine nacelle It lay amongrocks and boulders approximately 10 feet forward of its normal position with respect to the wing Nos 3 and engines were found with the wreckage of the fuselage and right wing and were lying slightly forward of their normal positions with respect to the wing, which was inverted The ring cowl of the No 4 engine had, in falling, been pierced by a small tree, which when examined was still standing and protruding through the cowl. Since this engine had remained at the approximate point at which it first made contact with the ground, it is evident that the engine m its final descent had little if any horizontal velocityThe nose cases of these three engines were ruptured to the extent that it was possible to examine visually the propeller reduction gear assemblies There was no evidence of gear or bearing failure or of any rotational inter- ference; neither were there any indications of abnormal internal heatNos 1 and 4 engines, lying among the boulders, could not be moved with-out the aid of equipment which was not available, therefore, examination of only approximately two-thirds of their power sections could be made No. 3 engine, however, could be moved, and its entire power section was examined Although the headers, baffles, and intake pipes of all three engines were generally crushed and distorted, no evidence was found indicating either in- flight fire or structural failure Neither was there any indication of power section failure, which would have been evidenced by power case rupture or loss of cylinders.All three engines suffered major fire damage to a similar degree The entire portions aft of the power case were completely consumed by fire, ex- cept for steel parts which were found in the burned rubble immediately be- neath the burned-out areas These engines also suffered from fire damage in the power section areas, being most extensive in No 3 engine In each instance, molten metal which had run downward with respect to the final position of the engines, indicated clearly that the fire damage occurred subsequent to impactThe measurements of the cowl flap jack screws converted to cowl flap openings indicated openings varying from 1 25 inches to 2 25 inches Waste gate positions of Nos 3 and- engines were found to be approximately I'1 to 1|-" from the closed, position                                                                                                                                                                                                  Uhe information with respect to No 1 engine waste gate could not he obtained due                                                                                                                                                                                                                   to impact damage Examination of all compressors and turbo wheels gave no                                                                                                                                                                                                                   indication of rotational interference or failurePropellersHie propellers installed in Nos                                                                                                                                          3 and U positions were found, and. identified, with their respective engines Examination and study of these components, within the limits imposed by the facilities available m the jungle, revealed no evidence of propeller malfunctioning nor any evidence that they were not operable prior to impact with the ground.No 2 Position Power PlantExtensive ground and air search                                                                                                                            failed to locate the No 2 engine .ccessories or No with its mounted accessories or No 2 propeller  Examfnation, therefore,was limited entirely to those portions of No 2 power plant which were re- covered. With the exception of the left diagonal of the lower "V" strutassembly, the major portion of the engine mount structure from the ring mount aft to the point of attachment to the wing structure was recovered with the fuselage and right wing wreckageShe ring mount apparently remained attached to the engine. Hie ring attaches to the engine mount structure at five main points: two near thetop of the ring, one at the bottom, and one on each side Ihe failures at these five points were of two types: the forked ends of one bottom and the two top engine mount members separated from the ring mount lugs in a manner typical of a shear failure of the bolts The forked ends were intact, but the bolts were missing The other type failure occurred at the two attach points on each side of the ring At these two points the lugs themselves were torn from the ring mount, taking with them small pieces of the ring Biese represent the most forward portions of the engine mount recovered Hie engine mount tubes were broken off at their aft terminal forgings and showed discoloration from exposure to heat The terminal forgings, how- ever, suffered no fire damage or evidence of having been exposed to heatIhe aluminum drain pan attached to the forward spar showed no evidence of                                                      fire damageThe lower scoop assembly was found, by the ground, search party apparent- iy                                                      500 feet from the tail group, the nearest major aircraft component Ex- am                                                      nation of the scoop revealed, no evidence of any explosion or damage by either engine or propeller impact A forest fire had burned over this area resulting in exposure to heat of those parts adjacent to the ground An examination of the air inlet scoop showed evidence of                                                                                                                                                                                                                                                                    xposure to heat on upper surfaces                                                                                                                                                                                                                                     Areas on the aft face which were protected by folded-overSee Appendix B metal were comparatively clean, and cavities within the scoop were clean other than being coated by a light film of oil The upper rear portion of the scoop which is normally adjacent to the exhaust stack showed no sign of exhaust impingement The entry area of the scoop showed no evidence of fire damage The oil coolers remained m their normal position within the scoop assembly There had been an intense localized fire in their area, in which the molten metal had run or dripped downward with respect to the final in- verted position of the scoop The aluminum shroud which normally covers the exhaust system ball joint was intact, with no fire damage The exhaust Y joint, the waste gate sec- tion, the ball joint, and the flight hood showed no damage other than impact The waste gate was approximately one inch from the fully closed position The waste gate motor was found with the No 2 engine mount Its poten- tiometer was in the extreme clockwise or Waste gate closed position. The turbo compartment was broken open and the turbo extensively damaged. The upper pressure header of the intercooler was detached The lower header remained in place The inlet face of the intercooler was clean The cooling air exit face was oily, with some soot being evidentIn the airplane there are three emergency fluid shut-off valves control- ling the engine oil, engine fuel, and hydraulic fluid These valves normal 1y operate simultaneously by a gang-bar from the engineer's station in the cock- pit The hydraulic fluid valve was found in the fully closed position The position of the other two valves, one of which was not recovered, could not be determinedExamination of the main left landing gear doors revealed that the rubber bumpers and forward bulkheads of both doors were unburned, and the exterior of the ri$it door was oily along its hinge lineEmpennage Anti-Icer Heaters The empennage anti-icer heaters remained m position in the dorsal finThere was no evidence of fire, soot, or stains within the ducts around the heaters or adjacent structureLanding GearAll three landing gears were located in the main wreckage area                               The nose gear was identified and was still attached to a section of the                          fuselage The main oleo cylinder was still attached to the fuselage structure                          The left and ri^at drag strut remained with the nose gear assembly, but                          both were deformed and twisted away from their supporting structure                            Both wheels and tires were completely consumed by fire                      Both steering cylinders were in- tact but had been subjected to extensive fire damage The right main gear was found in an inverted position still attached by its fittings to the rear spar This assembly had been subjected toextensive burning as all wheels, tires, and brake lines had been completely melted away The drag link, still attached to the main oleo by the lower universal link, had been deformed by impact and fire The drag struts and retracting mechanism were broken away from the main oleo cylinder and had been severely deformed by impact and fireHie left landing gear was located in the main wreckage area approxi- mately 30 feet from the right main gear The oleo cylinder and piston were completely separated The torsion links had failed at the scissor bolt The drag struts, drag link, and retracting mechanism were separated from, their supporting assemblies and had also been severely deformed by impact and fire damage                                                            Both 'wheel and brake assemblies were completely burned Very little of the left rear wing spar Was located with this landing gearassembly due to the proximity to the main fire areaAll landing gear actuators corresponded to the landing gears 1 retrac- ted positionMiscellaneous EquipmentIn the fuselage area in the vicinity of what would be the center fuel tank location, the emergency landing gear and wing flap motor, emergencyhand crank, and a fuel shut-off valve were found All of these components had been extensively burned in the ground fire but remained in their near correct locationOne fuel dump valve was located still attached to the right rear wing spar web Examination showed this valve to be in the closed positionThe six COg cylinders of the fire extinguisher system were found and identified                                                                   These cylinders, four of which are normally mounted in the No 3 engine nacelle and two in No                                                                                  2 nacelle, had their control                          valves knocked off at the cylinder neck at                                                                                impact or had been subjected to severeground fire                                                                                                        fire damage to these cylinders was so extensive that it was Impossible to                                                                                determine if any of the cylinders hadbeen discharged prior to impactInspectionWith respect to N 1039V, the aircraft involved, testimony revealed that nothing was found during the overnight in-transit service performed at Buenos Aires, April 27, 1952, to indicate that the aircraft was not in an airworthy condition whe.n it departed Buenos Aires as Flight 202 on April 28, 1952 Testimony further revealed that as a part of the overnight in-transit service performed at Buenos Aires, each propeller blade was examined with the aid of magnifying glass for cracks or other possible operational damage Ulis par- ticular propeller examination was performed by the supervisor in charge of ni^it service Following the flimits arrival at Rio he Janeiro, the pro- pellers were again inspected, this time visually, and again nothing was found to indicate an unairworthy conditionResume of Propeller Testing and Service DifficultiesExamination of the vibration and service information concerning the Hamilton Standard propellers with which Pan American World Airways ' Boeing377 Ts are equipped revealed some interesting and pertinent facts As a background of the subject propeller, a brief review regarding the basis for vibrational approval, and some of the service difficulties subsequently ex- perienced, is found necessary.Hie basis for approval was established from a combination of laboratory testing on the subject type of propeller which determined the strength limits for this propeller construction, and from very comprehensive flight and ground testing of the                       engine-propeller combination, both in the subject air- craft and on the test                       stand.The initial test program of these propellers showed only two critical high-stress conditions to exist One occurred during low rpm running onthe ground during crosswind operation, which resulted in a placard, still required restricting operation between 1600 and 2,000 rpm under this condi- tion Hie other condition was felt by the manufacturer to be objectionable, resulting in modification of the propeller design, which corrected the dif- ficultyThe peak of the propeller stresses was found in the neighborhood of 1600 rpm during fli^it testing These stresses were within the safe limits established for the blade design, consequently, no rpm restrictions were considered necessary With less than two years of service experience, lon- gitudinal cracks were found in a number of blades in the outboard blade section, with cracks originating generally along the bond line between the core and shell portions of the blade, about four inches from the leading or trailing edge and parallel to the edge These cracks were found to be due to the black rubber filler in the blade breaking and allowing the steel shell of the blade to vibrate locally from aerodynamic buffeting At this point the blade design was again altered by using nylon-rubber filler instead of black rubber, the nylon filler being tourer and more resistant to shatter- ing A daily tap test was required, as an interim measure, to locate anyinternal voids that were occurring in the blades with the black rubber fil- lerOne service failure attributed to a longitudinal blade crack starting from a void in the black rubber filler occurred near Glenview, Illinois, on January 25, 1950. In this instance, the outboard section of the blade flew off, resulting in the engine being torn from the aircraft and requiring an emergency landing at Chicago A portion of the propeller blade skin was found lodged in the aircraft fuselage, resulting in a relatively sudden cabin depressurization This had occurred prior to complete propeller failure On the same day, an identical aircraft coming into Tokyo, Japan, lost an engine, which fell into the ocean Although the engine and propel- ler were not recovered., the same type of failure is presumed to have occur-red On March 29, 1951? the crew of another Boeing 377 felt a severe shock and vibration while descending for a landing at Idlewild, New York The altitude was approximately 3,000 feet, air speed 160 knots, and engines operating at reduced power No 1 propeller was feathered within seconds of the first shock, and the vibration stopped A normal landing was made approximately six minutes later, with an outboard section of one propeller blade missing and the engine drooping in the nacelle Subsequent examina- tion showed, that three of the six :                                                                                                     IlW  unt ring lugs had failed---file remaining three, together with the lines, cables, etc ,                                                                                                                              being all that held the engine on the aircraft                                                                     Again, on July 28, 1952, another Boeing 377, while being ferried, between Rio and. Port of Spam, required, a propeller to be feathered, due to extreme roughness Examination later revealed, that this was caused, by a transverse fatigue crack across the midsection of the bladeDetailed inspection of all service blades resulted in the finding                                                                                                                                                              of several other blades with smaller cracks progressing A still further                                                                                                                                                            de- tailed inspection, which required all leading edge deicing boots to be                                                                                                                                                          re- moved for closer inspection, revealed an additional blade with a crack                                                                                                                                                          ex- istingSubsequent fdigit vibration testing of the subject combination after the cracked blades were found was performed on this particular aircraft to determine if anything peculiar was present in this engine installation that was not found during the initial type testing conducted                                                                                                                                                         19U8 The only significant difficulty was in the neighborhood of 1600 rpm, where the vibra- tion stresses had increased about 1^ times the value previously measured Since it developed that about five percent of the total operating time, particularly where longrange cruise was involved, was at this rpm, all air- craft were placarded immediately to avoid any continuous operation in this critical range. As a result, there has been combined with the daily visual inspection of all'blades, a very elaborate and detailed inspection to be performed every 50-100 hours on all service blades on the subject combina- tion Such an inspection procedure had been set up prior to the discovery of the more recent blade cracks and has since been revised to include tighter inspection and rework limits, as set up m the Hamilton Standard Propeller Service Bulletins Nos 177 and 193 Ihe ground daily visual inspection is Intended to spot any serious or obvious blade difficultiesElectrical SystemAll electrical equipment, including generators, alternators, actuating motors, switches, relays, and instruments, was extensively da.Tna.gp.ci by impact and subsequent fire, and much of the equipment, for this reason, was uniden- tifiable No evidence was found of electrical short circuits having existed in any of the aircraft's wiringThe main power bus                                                                                                               normally located in the ceiling of the lower lounge was found in that general area of the wreckage                                                                                                                                              This bus consists of three main parts  the main generator bus, the main load bus,                                     the main generator bus, the main load bus, and a smaller r,Ltf shaped terminal bus                                                                                                      Hie mam generator bus was m one piece, except for a short portion of one end, which was missing. The entire "bus was bent in a long curve toward its terminal face. Six heavy 00 power leads were more orless intact and showed no evidence of electrical shorts having occurred Three limiter lug fusible strips were intact and showed no evidence of electrical overload Each of the 11 studs in the main generator bus was examined, and all were found tight with the exception of two, one of which was missing In the area of the missing stud, there was found a burned Irregular hole, vary- ing from approximately 3/U of an inch in diameter on the terminal surface to approximately lj inches in diameter on the back surface There was also evidence of copper deposits imbedded in the inner surface of this hole All studs showed signs of heating, and all insulation had been burned away from the cables, which remained attached to the busRadio and Electronic EquipmentAll radio and electronic equipment was completely destroyed by fire with the exception of the                 radio altimeters, the AMLOO modulator, and the RCA record player These                  last-named items were destroyed by impactOperations The operations group confined its efforts to the examination of suchitems concerning the flight as dispatching, take-off weight, load distribu- tion, refueling, weather, radio facilities, radio contacts, fli^it documents, and manual s required to be aboard the aircraft No irregularities were noted which would in any way adversely affect the operation and conduct of the flight. Neither was anything found to indicate that the aircraft was not in an airworthy condition upon its departure from Rio de JaneiroA study of the crew history revealed that Captain Grossarth                                              had been employed by Pan American World Airways since April 18, 19^1> and                                         had on August 19, 19^6, qualified as Master Pilot on the Latin American                                         Division His total accumulated time as pilot was 8,452 hours, of which 735 hours were in Boeing 377 aircraft                      His last route check was accomplished January 11 1952; last equipment and                    inst rument                      check, March 6, 1952; and emergency equip- ment check, February 23,                    1952First Officer L A                          Penn, Jr.,                       had been employed by Pan American World Airways since November 1, 19^2 He                                            was assigned as first officer on Boeing 377 equipment November 1, 1950; and his total time as pilot was 9^99 hours of which 1,13^ were in the type equipment involved His last equipment and instrument check was accomplished on November 5/ 1951Mr P L Stilphen became an employee of Pan American World Airways on June 23, 1939/ was promoted to flight mechanic on November 1, 19^/ and to first fli^it engineer on Boeing 377 equipment on March 15, 1952Mr L. R Holtzclaw had been employed by Pan American World Airways since October 22, 1941, as flight radio officer, and on December 16, 194-5 was promoted to senior flight radio officer.Mr. J T Powell held navigator certificate No 1051697 and pilot air transport rating No 98357 He had been employed by Pan American WorldAirways since August 2, 1946, as navigator and copilot, and on December 21 1951, was qualified as first copilot on Boeing 377 equipment.ihe aircraft involved was properly certificated, and all members of its crew held such currently effective certificates as their assigned duties re- quired.AnalysisA. INTRODUCTIONIn analyzing the factual data obtained during the investigation, it is necessary to fully consider the pertinent circumstances under which this accident occurred Ihese circumstances are as follows:Cruising flight on a magnetic heading of 3^3 at an altitude of 14,500 feet MSL (approximately 13,000 feet above the ground) wasplanned over the area where the wreckage was found.2    The weather conditions in the general area at the time of the accident were such that violent turbulence of the air appearsun~l ikely                                                However, due to the long distances between stationswhich report weather in the general                                                                          rea of the crash, no post tive statement can                                                             be made that a storm did or did not exist in the area of the                                                              crash An analysis of the weather condi- tions in that area                                                             indicates that no storms were occurring at the time and place of the accident and that the air was gener- ally smooth Apparently the winds aldft in that part of Brazil at the time of the accident were generally light and from a northerly to northeasterly direction.3    The last message received from N 1039V was a routine positionreport No radio message was received indicating any in-flight difficulties or impending disaster. With the reported unsatis-factory radio reception due to meteorological interference in the accident area, together with the scarcity of aeronautical radio stations, it is entirely possible that an emergency mes- sage could have been transmitted without its ever having been received, or not understood if received due to the language difficulties in that part of the world.The type of propeller blade with which this aircraft was equip- ped is subject to fatigue failure as the result of comparative- C1 5            Since No 2 engine and propeller were not recovered, they could not he examined to determine the cause of their sepa- ration from the aircraft However, it can be concluded from examination of No 2 engine mount, which remained with the aircraft, that separation resulted from the application of forces beyond that for which it was designed Similar sepa- rations of engines from B-377 aircraft in flight, due to excessive loads being applied to the engine mount, are known In all cases where the engine and propeller were recovered, examination disclosed that the separation resulted from a propeller blade failure and the resulting destructive load due to the propeller unbalance6 The distribution of the wreckage indicates that the structural disintegration, with the possible exception of No 2 engine mount separation, occurred in a very short interval of time and at a moderately high altitudeThese circumstances, in general, indicate the probability of an emergency occurring with little or no warning, which required the full atten- tion of the flight crew. Considering the density of the jungle vegetation in the crash area, the failure to find the No. 2 engine and propeller does not preclude rhe possibility that they are in the area covered by both ground and air search If so, the time interval between their separation from the airplane and the final disintegration of the structure was extremely short During the early part of the investigation, particular significance was attached to the burned electrical bus bar, located in the lower lounge, as being a possible contributing factor to this accident. The theory was that upon the discovery of severe arcing of the bus bar, as an emergency measure all DC electrical current was shut off, thereby initiating a series of events which eventually resulted in No 2 engine and propeller being torn from the aircraft Examination of the wreckage, however, revealed two very pertinent facts, both of which clearly indicate that the DC electrical cur- rent was still available througiout the aircraft when this occurred 1  As a part of the emergency procedure initiated in the event of the loss of an engine in flight, the fuel, oil, and hydraulic fluid shut-off valves of the particular powerplant involved are closed simultaneously by the actuation of a gang bar from the flight deck. These shut-off valves are electrically operated Althou^i the positions of the fuel and oil valves were not determined, the hydraulic fluid valve was found m the fully closed position 2   The No. 2 engine waste gate motor, which remained with the air- craft, was found in the waste gate closed position Separa- tion of the engine from the aircraft would have unbalanced the motor control, causing the waste gate motor to move from its normal cruising waste gate position to either the fully open or fully closed position In either case, electrical current must have been available for uhe motor!s operation For the above reasons, it appears most unlikely that the DC current was shut off at any time for any reason or that the heavy arcing at the bus bar occurred before disintegration of the aircraft beganDie significance of the wreckage distribution, together with other factual information revealed by detailed examination of the wreckage, throws additional light on the sequence of failure and subsequent disintegration.Numerous parts of the structure were covered with a film of engine oil. Die areas covered by oil include the left side of the vertical fin and dorsal fin, the rudder, the normally exposed portions of the upper surface of the left flap in the area aft of the No. 2 nacelle, the most rearward portions of the fuselage left skin found at the main wreckage site, and th left stabilizer                                    Since these pieces of wreckage were found at widely scattered points, as shown on the wreckage distribution chart, it is apparent that there wa                                                           an abnormally large quan-tity of engine oil discharged from the No 2 nacelle                                                                                   irea be- fore any of these parts separated from the airplane                                                                                   This, considered in conjunction with the determination that                                                                                 No. 2 engine mount probably failed due to high unbalance of                                                                                 forces, indicates the probability that the oil was discharged                                                                                 from the severed oil lines between engine and tank when the No. 2 engine separated from the                                   airplane. Since extremely violent maneuver^ would be more critical for the outboardengine mounts than                                   for Nos. 2 and 3, if appears that the emer- gency resulting in                                   disintegration was caused by a failure in either the No 2 engine or propeller rather than an emergency causing high accelerations resulting                                                                     the loss of the No 2 engine.A trough-shaped depression in the leading edge of the dorsal fin appears to have been caused by impact with a relatively lightweight object which had a flat surface approximately four inches in width and was moving rearward and slightly to the right A piece of cowling from the No. 2 engine appears to be the most likely object to have caused this damage.A small hole was, punched through the upper skin of the right stabilizer, and a tear in the upper fabric of the right elevatorappeared to have been caused by impact with an unidentified small object of light weight moving rearward to the right and downward This evidence merely indicates the probable separa- tion of objects from the airplane prior to the fuselage sepa- rationWith reference to the hole in the upper skin of the left horizontal stabilizer Just forward of the rear spar at Station 122, it is apparent that most of this damage was caused by the inboard end of the rear spar upper cap outboard of Station 130 after the upper cap had failed. However, in addition to zinc chromate deposits on the exterior surface 01" the skin, which were rubbed off the rear spar, there were also some gray smears similar to paint Analysis of these smears disclosed that they were cellulose acetate butyrate dope It is possible that the gray smudge was caused by elevator fabric being carried into the hole by the fractured spar end5 The tail secrior of the airplane did not bear any evidence of impact in fli^it from a large or heavy piece of the airplaneIn. addition, the separated pieces of the left inboard flap bore no evidence of impact with the tail end of the airplane, other than cable marks diagonally across the top skin of one of tne pieces It therefore appears doubtful that the left wing and pieces of flap passed rearward of the tail section prior to the fuselage separation 6. All flap actuator screws were found with the nuts at 13 to 14 threads from the retracted position, which corresponds to a few degrees flap extension This is not normal for cruising fli^it It suggests the probability of an attempt by the crew of N 1039V to stop tail buffeting, which could be caused by dis- turbed airflow over the No 2 nacelle minus its engine Although at least one B-377 is known to have lost an engine without se- vere buffeting, differences in the distortion of the cowling and the amount that hung on to the nacelle could very easily be the determining factor as to whether or not buffeting occurs in a particular caseConsidering further The wreckage distribution, it is significant to note again the close grouping of parts from various extremities of The air- plane; namely, the outboard section of the right aileron, the center third of the left elevator, the rigJiT-hand nose wheel well door, the inboard sections of the left flap, and the cuter half of the left stabilizer. These pieces were found within an area encompassed by a circle of approximately 350 feet radius As these pieces are fairly uniform in density, it is apparent that all separated from the airplane in a very shorT interval of time It is significant, then, that the bearing from the center of this circle to the tail section wreckage was approximately 3^-0 degrees or practically identical to the intended track of the airplane over this area The winds aloft were probably light from a northerly to northeasterly direction; therefore, they would have comparatively little effect on the relative paths of these pieces of wreckage in falling to the ground from high altitudes Since the left flap obviously broke up as a result of the left wing failure and the pieces of flap came to rest near pieces of the left elevator and stabilizer, it is apparent that there was practically no time interval between the wing failure and the tail separationThe location in which the No. 2 engine scoop was found fits m with tnis reasoning as to the flight path of the airplane when disintegration occurred, since the path of the scoop shown on the wreckage distribution chart appears to have resulted, from the dense piece of wreckage having first struck                                                                                                                   a rock from which it ricocheted along the ground on a bearing of 200 degrees                                                                                                                    How-ever, the location in which the intercooler installation parts of the                                                                                                                    No. 2 engine were found is approximately 1,000 feet east of where one would                                                                                                                    ex- pect to find them if they separated from the airplane while it was making a track of 3^3 degrees Qhe location of the left                                                                                           wing and the main wreckage relative to---the other pieces is not inconsistent,                                                                                       since these two parts con-sisted largely of unstable lifting surfaces which                                                                                         could modify their path of descent from fairly high altitude to a very great                                                                                         extent In addition, the engines could have produced thrust during a                                                                                 or part of the                              descent, fur- ther affecting the path of descent.Considering all of the above evidence and reasoning, it                                                                                                                 appears that the emergency originated either in the No                                                                                 2 propeller or engine                                  It appears that very shortly after thi                                                                     left wing failedAlmost simultaneously and as                                                                    a result of violent pitching of                                                  the air- craft during the wing separation,                                                               entire tall group broke from the                                                 fuselage in a downward direction at a point just aft of the dorsal fin, probably before the left wing proceeded that far rearward.POSSIBLE CAUSES OF STRUCTURAL DISINTEGRATIONTie probable sequence of failure indicates to some extent the prob- able cause of the structural disintegration However, as it does not giveclear-cut proof, it is necessary to consider other possible causes of struc- tural disintegration. Since the weather does not appear to have had any bearing on Hie accident and since continued cruising flight over the area of the accident was intended, numerous possible causes of structural disinte- gration are eliminated without further analysis Hie remaining possibili- ties are analyzed in the following sections on the basis of available infor- mation :Explos ionDue to the apparent suddenness of the disintegration, the theory of an explosion causing the accident gained some credence How-ever, examination of the wreckage disclosed no evidence of dis- tortion of a nature which would be caused by an explosion in the airplane Althou^i the central portion of the fuselage was com- pletely destroyed by impact and subsequent fire, a number of components, which are normally located in this section                                                                              , still remained in their relative positions However, the fi could have obliterated possible evidence of an explosion Nevertheless, it appears that any explosion in this parr of the airplane which would have been severe enough to cause the acci- dent should have caused the fuselage to separate at either the front spar station or the rear spar station Ihis did not occur and no evidence was found to support the explosion theory 2  Sabotage Examination of the wreckage disclosed, no evidence of sabotageHowever, due to the extreme destruction in the central portion of the airplane, evidence of many types could have been ob- literated. Nevertheless, the type of sabotage most likely to cause a very sudden disintegration, namely, a bomb exploding, is extremely unlikely as discussed above. 3  Fatigue Failure of the Airframe Any fatigue failure likely to be a direct cause of sudden disintegration should occur in one of the heavy load carrying members, such as the wing spar caps Careful examination of the wing spar caps in the area where the left wing separated disclosed no evidence of fatigue cracking Only indications of extremely high tensile stresses were in evidence These indications point to upward failure of the wing due to exces- sive aerodynamic loadsNumerous other fractures throughout the structure were exam- ined for evidence of fatigue cracking, without any being found. It can, therefore, be concluded that fatigue failure of a structural member of the airframe was not the direct cause of the disintegrationOne theory which has been advanced as a possible cause was loss of the left nose wheel well door which then collided with the No 2 propeller, resulting in unbalanced forces which tore the engine from the aircraft The loss of a nose wheel well door could result from fatigue failure of one of the attachments However, the only portion of the left nose wheel well door identified was a small fragment attached to a piece of fuselage structure^ by means of the rear hinge The edges of this re- maining door fragment were all curled inward, and the door structure immediately adjacent to the hinge showed no evidence of twisting deformation. If the front hinge had failed in flight due to fatigue or any other cause, allowing the front end of the door to drop down and to cause enough, drag to tear the door off, the skin forward of the rear hinge should be curled outward and the structure adjacent to the rear hinge should show twisting deformation. It appears probable, there- fore, that the left nose wheel well door did not twist off in fli^t and strike the No. 2 propeller4              Fire in Flight Weakening StructureNumerous indications of fire as a result of impact with the ground and burning due to the jungle fire months after the accident were found. Although it is possible that some of this fire damage could have obliterated any evidence of damage due to fire in flight, a sufficient number of the pieces of wreckage which separated from the airplane in flight were found with either no fire damage at all or only minor damage resulting from jungle fire. Examination of the wreckage dis- closed no evidence of fire in flight, consequently, the disintegra- tion of the aircraft did not occur as a result of weakening of the structure from this source.5-  Hard-Over Signal from AutopilotIhe autopilot was so completely destroyed in the ground impact and the subsequent fire that no information could be obtained from examination of it However, the establishment of limiting torques intended to prevent the application of                              loads in excess of the structural strength was included in the                              type certifica- tion of the Boeing 377- Therefore, structural                               dis inte gration due to excessive loads caused by a hard-over s                                        11 autopilot appears highly improbable.6.  Malfunctioning of Rudder Boost SystemExcessive loads due to malfunctioning of the rudder boost system are possible However, the rudder boost system on the Boeing 377 is normally used only for take-off and landing Examination of the Geneva-loc type shut-off valve in the rudder boost panel disclosed that it was in the closed, or boost off, position. Since this type of valve is secure against actuation except by the normal electrical motivation, it is evident that the disintegration was not due to excessive loads resulting from malfunction of the rudder boost system7-  Collision with. Foreign ObjectAs pointed out previously, little evidence of impact damage in flight was found What was found appears to have been the re- sult of the initial disintegration rather than its cause,                                             1 possibility of a piece of propeller blade piercing the fuselage has been considered As pointed out under investigation, evi- dence of such damage was not found. However, due to the severe melting of the fuselage m the region of the inboard propellers, most of the fuselage skin could not be identified However, even if a piece of propeller did slash through the fuselage, it would not necessarily result m disintegration If disintegra- tion did occur due to weakening of the fuselage structure m this area, the fuselage should have parted at this point, which it did not. If a piece of propeller blade slashed control cables, the airplane could become uncontrollable and develop See our selection of avi^joon documents at RareAviation.comexcessive loads, causing disintegration. However, the manner in which the primary control cables failed Indicates they were Intact until the structure started breaking up It, therefore, appears improbable that structural disintegration was the re- sult of the control cables being severed by a piece of propel- ler bladeAnother possibility to be considered is a bird strike on the windshield No evidence of this was found on the recovered portions of the windshield or frames . Due to the cruising altitude of 14,500 feet MSL, it is improbable that any bird would be flying at that altitude. However, even if a bird strike did occur, it is unlikely that it would incapacitate both the pilot and the copilot It, therefore, appears highly improbable that the structural disintegration resulted from collision with a bird8 Buffeting and/or FlutterNo indication of flutter, as such., prior to disintegration was found by examination of the wreckage, although particular at- tention was paid to the condition of control surface hinges and balance wei^its for indications of looseness and working. As pointed out in Item B (6), above, the finding of the nuts on the flap actuator screws m a position corresponding to a few degrees 1 flap extension strongly suggests an attempt on the part of the crew to stop buffeting. Hie slight extension of the flaps also suggests the possibility that disintegration occurred before the flaps were extended as far as the crew may have intended.Examination of the tail assembly wreckage disclosed evidence of the application of very hi^i loads in both the up and down directions, as would result from buffeting Examination of the break in the left stabilizer indicated further that after par- tial failures had occurred in the spars and shell, the outer portion of the stabilizer oscillated up and down through several cycles before separating from the inner portion Buffeting is the most likely cause of such oscillation. The more severe in- dications of buffeting on the left stabilizer than on the right stabilizer fit in with the No 2 nacelle being the source of the disturbed airflow. As a result, it appears probable that severe buffeting, set up by the No 2 nacelle after the engine separated from the airplane, was more severe on the left sta- bilizer than on the right and caused a partial failure of the left stabilizer at about its mid-span while only causing wrink- ling of the upper skin of the right stabilizer While the outer portion of the left stabilizer was still hanging on and oscillating up and down, it may have disturbed the hinge line in such a manner as to snap the elevators upward, causing a very hi^a down load on the horizontal tail surfaces sufficient to cause a great increase in lift on the wing and upward failure of the left wing,                                                                         05ie nose down pitching accelera-tion of the airplane vhen                                                                       the wing failed the tail, would then he likely to cause the tail assembly to fail downward.Another possible cause of buffeting, one which caused an II        II                                                                     tl N 1027V, between Galeao Airport, Rio de Janeiro                                                                                       , and Port of Spain on April 10, 1951, should be considered.                                                                                       Distortion and weakening of the left door of the nose wheel well, by inter- ference with the nose wheel during retraction, resulted in a gap at                                  its leading edge when the door was in the closed posi- tion.                                   At cruising speed the discontinuity at the leading edge door apparently was sufficient to cause the forward partof the                                  door to snap down into the wind stream and cause suffi- cient turbulence to create violent buffetingComparison of this case with the known facts                                                                                 relative to N 1039V does not permit a positive finding relative to the left nose wheel well door on the basis of the physical                                                                                 evidence, since most of the left door was never identified                                                                                   However, a dis- torted nose wheel well door does not appear io be a likely cause of the disintegration of N 1039V, for the reason that the accident occurred hours after the airplane reached cruising altitude and speed. If a distorted door had been the cause, it should have caused buffeting as the airplane was approachingII nation of the nose wheel well ri^it door eliminated it as a probable cause of buffeting," since it bore no distortion thatwould be likely to cause buffeting. Distortion at the front end was obviously from impact with the ground The only other distortion was caused by the door being blown off the airplane by excessive air loads acting on the door to the right while the door was in the open position. Experience with a military model of aircraft similar in design in many respects to the Boeing 377 which has disintegrated in flight, indicates that when the left wing fails, the right nose wheel well door can be expected to tear off in this manner in the violent left slip that results from the wing failureStill another instance of severe buffeting has been reported involving the Boeing 377 while on a night training fli^at in which third pilots were making qualifying take-offs and land- ings at Idlewild, New York. In this instance, while operating at an altitude of 1200 feet with No 1 engine windmilling as a result of oil difficulties and Inability to feather the propeller the engineer, to put out a suspected engine fire, opened the engines' cowl flaps to their maximum instead of the normal 2g- opening prescribed. -Ihis cowl flap setting, in combination with the windmilling propeller, created such severe buffet- ing and vibration of the aircraft that only with great diffi- culty was the pilot able to hold the left wing up or maintain directional control The engineer, upon realizing that the difficulty was caused by the cowl flap position, closed them and the buffering and vibra              tlon stopped   huh   sdiately      However, during this period the aircrafcs altitude had dropped to 500 feet and was maintained only by the use of full rated power on the remaining enginesNo evidence was found to indicate cowl flaps were in any way involved in the accident under discussion. However, thisincident clearly shows the serious buffeting effect which may be induced on this model aircraft by any abnormal air flow such as undoubtedly existed following the loss of No. 2 engineAdditional experience in several accidents to the same military model which involved extremely violent maneuvers due to several causes brings to li^it a striking similarity in the failures on N 1039V Biese include failure of the stabilizer at about the mid-span, failure of the aileron at the out                    mi*   st hinge, loss of wing gap seals, damage to the wing between tne inboard and out- board nacelles, and, as mentioned above, loss of nose wheel well doors in violent slips.Findings1 The carrier, the aircraft, and the crew were properly certifica- ted2   3he flight was operating under VFR conditions, and weather is not considered a contributing factor 3   The fli^it was routine to the abeam Barreiras check point, where it reported at an altitude of 14,500 feet 4   The No 2 engine and propeller separated from tne aircraft in f ligit.5. The aircraft, for reasons undetermined, became uncontrollable following the separation of No 2 engine and propeller, resulting in the loss of the left wing and the tail assembly6 There was no evidence of fire in flightProbable Cause The Board determines that the probable cause of this accident wasthe separation of the No 2 engine and propeller from the aircraft due See our selection of aviatioon documents at RareAviation.com - 32 -to fairly unbalanced forces, followed by uncontrollability and disinte- gration of the aircraft for reasons undetermined.BY THE CIVIL AERONAUTICS BOARD:s/ HARMAR D. DENNY/s/ JOSEPH P. ADAMSOswald Ryan, Chairman, did                net participate                                 Xu the adoption of thisreport. SUPPLEMENTAL DATAlovestigation and. HearingOn April 29, 1952, at approximately 1348, the Civil Aeronautics Board's Miami Branch Office was advised by the Pan American World Airways' Miamioffice that their Fligit 202, which departed Rio de Janeiro at 0217 and due to arrive at Port of Spain, Trinidad, at 1321, had been unreported since 0615. This information was immediately transmitted to the Civil Aeronautics Board, Washington, D. C. An air search was begun at 1445 on the same date, and at. 1800, May 1, 1952, the Civil Aeronautics Board was advised that the wrecked aircraft had been located in the remote Jungle of Para State, Brazil. An investigation was immediately begun 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 which was held in Miami, Florida, November 10-14, 1952.Air CarrierPan American World Airways, Inc., is a New York corporation, having its main offices at 135 East 42nd Street, New York City. It operates as an air carrier under currently effective Certificate of Public Convenience and Nec- essity issued by the Board and an Air Carrier Operating Certificate issued by the Civil Aeronautics Administration. Uiese certificates authorize the company to transport, by air persons, property, and mail between                       various points in the United States and those of foreign countries, two                        of which include Rio de Janeiro and Port of Spain.Fligit PersonnelCaptain Albert Grossarth, age 27, held currently effective                            Airman Cer- tificate No. 70338-41, with an airline transport rating. He had accumulated a total of 8,4-52 hours as pilot, of which 735 hours were on Boeing 377 air- craft. He had his last route check on January 11, 1952; his last equipment and instrument check on March 6, 1952; and received his last CAA physical examination on March 11, 1952.First Officer L. A. Penn, Jr., age 34, held currently effective Airman Certificate.No. 93702, with airline transport rating. His total time was 9,099 hours, of which 1,134 hours were in Boeing 377 equipment. His last equipment and instrurnent check was accomplished on November 5, 1951, end his last CAA physical on December 27, 1951-Fli^at Engineer P. L. Stilphen, age 37, had been employed by Pan American World Airways since June 23, 1939; was promoted to fli^it mechanic November 1, 1942; flight engineer November 23, 1945; and flight engineer on Boeing 377 equipment March 15, 1952. His total fligit .time was 6,991 hours, of which 216 hours were in Boeing 377 equipment. He held Fligit Engineer Certificate No. 1019695- Radio Elicit Officer L. R Holtzclaw, age 32, had. been employed, by Pan American World. Airways as radio officer since October 22, 1941 His last CAA physical was accomplished on September 6, 1951, and he held currently effective Flidat Radio Operator Certificate No 1017841, issued by the Civil Aeronautics AdministrationNavigator J T. Powell, age 3^, had been employed by Pan American World Airways since August 2, 1946 In addition to holding current Navigator Certificate No 1051697/ he held Airman Certificate No 98357, with airline transport rating. His total flight time was 8,980.                                                                                                    His last CAA physical was accomplished on January 10, 1952He AircraftN 1039V, a Boeing 377 aircraft, Serial No. 15939, was manufactured in September 19^7 and purchased by Pan American Airways, Inc., on August 27,1949. During the period between manufacture and delivery to Pan American, this aircraft was used by the Boeing Company as a flight test article in the determination of performance, control, and stability and for functional tests of various pieces of equipment On completion of the fli^it test program in October 1948, the aircraft was returned to the factory for modi- fication to the CAA approved configuration and to complete the airplane for customer delivery. Ibis work required approximately nine months to accomp- lish.       ---------------- -------- --- -----u-----r-1 Upon completion the aircraft was delivered to the customer after 5y hours of                                           additional routine production and acceptance flight testsThe aircraft was equipped with Pratt & Whitney R-4360 engines and Hn.-milton Standard Model 24260-43 propeller hubs, with Model 2J17-8W bladesThe total time of the aircraft was 6,944 hours. On July 8, 1951, the air- craft was given its last No. 5 check, at which time it had 6,424 hours' flight time.Die following shows the total time and positions of the engines and propellers prior to departure from Rio de                                                                                Janeiro on April 28, 1952:ENGINE INFORMATIONPosition                              Serial                      Date                        Time Since               Total No                                 Number                    Installed                          Overhaul               Time3732 23 1                                  2001                  4/10/52                                 126 *46 2                                  2043                  12/12/51                                917.46             3824.393                                       522              1/ 6/52                                 765 18             268553 4                                  1794                  1/27/52                                 616:14             3706:08nnfiM        INFORMATIONPosition                        Serial Date                                          Tune Since                    Total No.                          Number                  Installed                     Overhaul                      Time 5041 1                  163252   4/9/52                                            1281 2                  163613    4/12/52                                           589                4495 3                  163117   V5/52                                              167                4559 4                  163035    12/19/51                                          866                6449 TRACK 0*4W                                                                                                                                                                                                         --- ihflRtaautB JOT, nTB *F   US. 6  CNO 69                                SCOOP                                                                                                                              4 cl XU'? x***oo'                                                                                                                                                                                              x->. 70<J 9 X-LK STAfiKZfff O (OUTER HAL/) ' 600                                                       0 B 0 SECT. AUROh                                                     o rx:                                                              10SB WXKtL DOOR { R.H.)5oO                                                                                                                                ? ----UAP..100no                                                                                                               niTl                                        -ElIVATOR iCBMTER I/*)ioMO!'                                                            aWRECKAGE 'DISTRIBUTION CHART ---RA.A. BOEING 8-377 NI039VNEAR CAROLINA,BRAZlC^APRIL 29,1952 (.0 CAT. 9*45'6" SOUTH V,               LCfHG. SD*^ry W ST / 350- LOOKOUT SOCK                    >AP COVER                                      SCALE : ONE CENT/METER = ONE HUNDRED FEET l50'                                                                                                                        ALL BEARINGS MAGNETIC .MV o 3'.AIM       WRECKAGEVARIATIONRttK AGE 4NYCR7E3E.D-A. WJjS KEYLEFT WING *2 ENGINE SCOOPTAIL ASS'y FLAP . LOOKOUT ROCK MAIN WRECKAGE AIR sbarchkp                                                         ADVANCED GAMP 20 S.M. FROM FLAP  AIR SEARCH COVERAGETYPICAL AIR SEARCH LEG:                                                                                      AIR AND GROUND SEARCH OVERHEAD LEFT WING Q                                                                                         COVERAGEOUTBOUND HEADING! 315*INBOUND HEADING : 135* NEXT LEG. 320*-140 ANO INCREASING EVERY 5* THROUGH COMPLETE 360* COVERAGE. (TURNS NOT DRAWN TO SCALE)MAA. H.AIR SEARCHED 20 S.M. FROM FLAP >*H IO*OPVARIATION H* W AIR-GROUND SEARCH                     FOR *2 ENGINE-N1039VSCALE :           3h ONE MILE DIAMETER INNER CIRCLE: TWO MILES DIAMETER OUTER CIRCLE: FOUR MILESU.A. XUU75From PilotManuals.com / RareAviation.com Z3 /a File No. 1-0062 CIVIL AERONAUTICS BOARD ACCIDENT INVESTIGATION REPORT Adopted; October 29, 1952                 Released: October 31, 1952 PAN AMERICAN WORLD AIRWAYS, INC. - NEAR RIO DE JANEIRO, BRAZIL, JULY 27, 1952 The Accident The main cabin door of Pan American World Airways Boeing 377, N 1030V, 1/ opened suddenly during pressurized flight at about 1446 GUT, July 27, 1952* Out-rushing air blew overboard a woman passenger who had been in seat No 33> closest to the door The aircraft vras at an altitude of about 12,000 feet and was pressurized to a differential of 41 pounds per square inch At the time the aircraft was over ocean outbound about 18 minuses from Pio de Janeiro, Brazil, at about Latitude 23 30* s arri Longitude 43 40f W. History of the Flight This flight, designated by PAUA as Flight No. 201 of July 26, 1952, originated at New York International Airport (Idlewild) Its destination was Buenos Aires, Argentina, Soutn America, wi^h stops scneduled at Fort of Spain, Tnniaad, BWI; Rio de Janeiro, Brazil; and Montevideo, Uruguay Crew changes on Flight No 201 were made at Port of Spain and Rio de Janeiro From Idlevild to Port of Spain the flight was routine, with no reported difficulty in the functioning of the main cabin door except for the pursers later statement, "I found the door handle to be quite difficult to opdn or close.1'1/ Greenwich Mean Tinea                    Rio de Janeiro time was 1146 The same type of routine operation was experienced on the second leg ofthe flight, frem Port of Spain to Pio de Janeiro, again with no reporteddifficulty in the functioning of the main cabin doer except that the purseron this leg later stated                 "The only thing noticed was a slight aiffaculty ir                t-locking the door which is                not uncommon on the B-377* Neither purser, however, considered the deor                handle difficulty of sufficient importance to reportThe aircraft landed uneventfully at Rio de Janeiro and                        was serviced and loadedfor the next portion of the flightThe crew from Eio de Janeiro consisted of Captain                            G L. fly, FirstOfficer R. a. Sylvester, Flight Engineer J, Ds Knight,                        Radio Officer 0* EDonaldson, Purser G, Ao Oliva, Stewardess Le Hill, and                        Stewards R. Garcia andM. k. Dominguez. There were 19 passcngers0 Tne aircraft was so loaded thatits center of gravity was within prescribed limits, and its total weight was6,660 kilos (121|, 935 pounds) as compared with its maximum allowable take-offweight of 60,191 kilos (132,721 pounds) The flight plan was according tinstrument flight rules at an altitude of 6,000 meters, or approximately20,000 feetoafter the aircraft was loaded, the main cabin door was closed andsupposedly locked by ground personnel and the position of the msido nandlechecked by the purser, as was routine practices During the cockpit check,prior to starting the engines, a cockpit warning light remained on indicatingthat one or more of the cabin doors (two cargo, one galley and tho mam cabin)was not locked. Accordingly, tne flignt engineer inspected the two cargodoors and the main cabin doore (The galley door was inspected by groundpersonnel and pronounced locked, via interphones) The flight engineer noticedthat the handle of the main cabin door was not in the horizontal (locked) - 3 - position. He opened the door, closed it, and turned the handle as far asit would go toward the horizontal (locked) position. He estimated that the handle was within about 25 of the locked position. The flight engineer testified that he used a flashlignt to check the positions of the four bolt mechanisms and the pressure lock visible tnrough their respective inspection windows on the inside of the door. All seemed normal. He then reported to the captain that all doors were lockedv The engines were started, and the aircraft left the ramp and took off at 1U28. During this time the door warning light remained on* A climb was started, as was caoin pressurization. At an altitude of about 12,000 feet and with a cabin pressure differential of l|tl pounas per square inch, corresponding to a cabin altitude of about 2,000 feet, the purser heard a loud hissing noise at the cabin door. He went to the flight deck and stated to the captain, lrWe should depressurize because I think the door is open,11 The captain ordered the flight engineer to inspect the door. (The door warning light was still on.) The first officer assumed the station of the flight engineer who went aft with the purser. Both inspected the door while the captain stopped the aircrafts climb. The flight engineer did not make a visual inspection through the door windows but placed his hand along the top edge of the door, whereupon the noise decreased. He then instructed the purser to place wet towels m that area to reduce the air leak and the noise. At -this time the door handle was still not in the locked position, the flight engineer estimating that it was still about 2o from being in the horizontal position and the purser estimating it to be only about 19 from the vertical, or fully unlocked position The purser then went aft in the cabin to procure towels. The flightengineer returned to his station and reported to tne captain that the door seal was leaking but everything seemed normal                                                           The captain elected to continue.The door warning light was still on. Within a minute or two, at tnc cabin door blew open, stated,a woman passenger m scat flo, 33, nearest the door, went through it. IJono ofthe other occupants was injured although many of them experienced a temporaryoar discomfort as would occur following a rapid depressurization. The deprcssurization, of an explosive violence, caused damage throughout the cabin,blowing loose celling panels and many sections of soundproofing and up-hoistcry and tearing off the- door of the ladies lavatory. Fog, caused bycondensation at the lower pressure, temporarily filled the cabin.The aircraft was immediately turned back to Rio de Janeiro where itlanded uneventfully at 1513# forty-five minutes after taking off. During theentire flight the weather was good, witn little or no turbulence. The dooropened                                                               while the aircraft was on course for Montevideo and about seven minutesafter passing abeam of Santa Cruz.Upon notification of this accident,                                                  the Brazilian Government immediatelyinstituted an intensive air, s^a and shore scarce for the body of the missing passeTgvr. This search was futile.investigation When the flight returned to Rio de Janeiro, local authorities immediatelyplaced the aircraft under guard, Passengers w                                                         c            re deplaned, questioned andpermitted to le'-ve on a subsequent flightaAn accident investigator of the Civil Aeronautics Board, at that time ontemporary duty at Rio de Janeiro, took part in the investigation at the invitation of the Director of Civil aviation for Brazil. As the main cabin door, its locking mechanism and the manner of its opening will be discussed at some length, it is appropriate hero to describe that door and its associated safety devices# The door opens outward and is nung on two hinges at its forward edge It has both an external and an internal locking handle# The external handle is approximately nine inches long and is mounted at its center on the locking shafto The internal handle is a lever about nine inches long mounted at one end on the same locking shaft# Normally, these two handles remain parallel. The door is completely unlocked when the handles are approximately vertical with the internal handle upward# It is fully locked when the handles are approximately horizontal, iQc#, when tnc internal handle is turned counter-clockwise to a horizontal position* The outside of the door is marked with two curved arrows showing the directions to turn the door handle, "to unlock" and "to lock#11 The inside of the door has a single arrow curved clockwise, marked "turn handle - opens out# Rotation of the door handle shaft actuates a mechanism t: at extends orretracts 13 locking bolts, ccmnonly called bayonets, placed arcund the edge of the door. There are two of tn^se bolts on both the top and uhe bottom of the door edge, five on the forward edge and four on the aft edge# These bolts are extremely hard and are polished# Their full travel from the unlock to the lock position is approximately 1-3/8 inches# The outer ap roxunate nalves of all 13 bolts arc tapered in both width and thickness o Around the door frame are 13 receptacles which receive the bolts# Sachis capped with a striker plate with an orifice into whicn the fully extended bolt fits snugly# The inside of the door is fitted with five clear plastic winotns, One,located on the lower rear, allows visual inspection of the doors pressurelock. The other four, two at the top and two at the bottom of tne door, allowvisual inspection of the positions of the mechanism actuat .ng the four bolts(bayonets) located immediately adjacent to the bases of the boltseThe Pan American B-J77 operations manual, carried aboard the aircraft,describes completely the locking mechanisms of the various exterior doors of the aircraft and their safety devices*---/ A description of trie main entrancedoor locking mechanism is quoted as follows:Pressure Leek: To prevent anyone        from in- adveruen'ly opening tne door wnen       the cabinis pressurized, the pressure lock       acts to prevent movement of the lower cable system* The lock is energized continuously when cabinpressure differential exceeds 2" HpO, Engage- ment of the pressure lock may be crocked through the square window on the lower aft portion of the door.Latch Dog lock: This lock prevents damage to 13 latch acgs by locking all dogs in the re-trained uosition when the door is            opened and thus pre rents slamming door closed on the open lauon dogs. This lock is automaticallyoperated by a small striker plate in the upper forward nortion of the door.Vibration Lock: To prevent the aoor latching dogs from working loose due to vibration, tnevibration look automatically engages a locking pin in the door handle sprocket wnen the door landle is turned into the locked position. During the first 30 degrees of unlatching, the rotation of the door handle acts to disengage the vibration lock pin from the door hanule spreeketo2/ PAA B-377 operations manual, aircraft description of exterior doors, item 87OH (1) and (2), puolished August lit, 19^1. 4, Anti-Rotation Latch: This is a sprmb catch type anti-rotation "latch installed under the lining of the door handle shaft* It serves to prevent rotation of handle toward the unlocked position due to vibration, serving the same purpose as tnc vibration lock*Cord: In event of failure of the vibration lock the bvngce cord applies suffi-cient tension to the door handle to maintain it in the locked position and thus prevent the locking mechanism from working loose due to vibration*TO CHECK M^IN CaFIN LOOR PROPERLY LOCKED "   - *  '*                          --- * - --- ---  I   Handle Position                                                  Handle should be horizontal, and against internal stop If handle is not horizontal when it is against stop, write up for Maintenance actionBungee Cord                                                     Cora snould be attached from rear end of handle to tnc lower portion of the door*Pressure Lock                                                    When pressure differential ex- ceeds 2 HgO, dogs should be in position to prevent cable from being jnovea sufficiently to scuuaue door Inches c The lack- ing dogs are viewed througn square Winuow in aft lower portion of GOO7"*Door Latches                                                     Door Intones may be viewed through the foil circular windows, two at the top ana two at the bottom of tnc door, Latch mechanisms should be in locked position*WOWING 1. In event of mam entrance door air leakage*the area in front of the door should not be used for food service cleaning purposes* In event of mam entrance door air leakage, do not touch the door handle. Any attempt* to adjust handle during pressurized flight can only lead to further opening of the doorThere is installed in the B-377 aircraft a door warning system. It isdesigned to alert the crew to any malfunction of the main entrance cabin door,forward cargo door, rear cargo door and the galley loading door by                                                          means ofa warning light in the cockpit.                                                   At the rrain cabin door tncre arc twodoor-closed micro-switches installed in the door frame, one for the upper cable system and the other for the lower cable system, and one door-lockedwarning switch under the door lining, actuated by the vibration lock. Thesemicro-switches are installed to cover not only the complete traveling actionef the locking door bayonets, or bolts, but also to cover the completerotation of the doer handle to insure that the vibration latch and theanti-rotation latch are completely secure# These switches are so locatedthat they can be readily inspected at al] times.The B-377 operations manual                                                   "Aircraft Description Exterior Doors1                   alsoincludes instructions when the door warning light comes on in the cockpit.These instructions, in part, are as follows:"If the warning light remains illuminated after all doors are closed and locked, the following should be checked OsK, prior to takeoff: Main entrance door .                                             Four latches fully closed (check thru U windows)Door handle m locked position 3          Bungee cord attached."Examination                                        f the cabin main entrance door was made at Rio de Janeiro.Damage to 1hc door was confined tc downward distortion of botn hinges, aThe forwa4 cracked lower hing^ and tnr^e rivets missing fren tne lower hinge* See our selection of aviatioon documents at RareAviation.com - 9 - edge of the aluminum metal window frame in the door was distorted rearward, and a small section of upholstering fabric at the center rear edge was missing. A deep indentation and slight displacement of tne rubbrr door seal * near the doors upper rear corner was found and there was a small indentation of the rubber seal near the doors lower rear corner. Damage to the door frame was confined to a slight depression of the frame metal near the upper rear corner. The rubber seal across the top of the frame was missing. The remainder of the frames rubber seal appeared , to be somewhat deteriorated, The mating indentations in the door and its frame were of such size and nature that they were obviously caused by the loosened and wedged door frame seal.^/ No evidence of failure or malfunctioning of the main entrance door looking mechanism was founds All rigging adjustments that could be checked were found to be within acceptable tolerance. This included the micro-switch actuator adjustments, the bayonet extensions, and all other checks except the cable tension check, the pressure switch pressure check and the anti-vibration lock plunger clearance check. The pressure switch secondary Lock was actuated by connecting a rubber tube to it and blowing tnrough the tube. This properly locked the mechanism and made it possible to measure the clearance which was within the tolerance specified by the CAA approved company maintenance manual. No tensiometer was available with which to measure the bayonet lock actu- ating cable tension. The upper cable appeared to oe adjusted approximately to the required tension of 30 to UO pounds but the lower cable appeared to retain only about half of that tension. There appeared to be seme abnormalSee Attachment A See our selection of aviatioon documents at RareAviation.com ~ 10 -play in the actuating mechanism during operation of the handle but it didnot affect the proper locking of the door during tests.It was not possible to close the main entrance door until the hingeswere disconnected. When tms was done trie door was closed, the aircraftselectrical power system was actuated and the door was locked. During thistest the door warning light actuated properly and the door handle moved fullyto its horizontal                                                locked position. The door was then unlocked and tne flightengineer involved                                                while standing in the cabin, moved the locking handle asfar to the left as                                               he remembered moving it just prior to the flight involved.This position was at a point midway between the unlocked and lockedpositions which was at an angle of aoout rearward from vertical. Theflight engineer then continued the leftward movement of trie handle until itwas fully in tnc horizontal position. During this latter test, une doormoved noticeably inboard, as is normal.All 13 bayonet wells m the door frame lock plates were examined forforeign matter. A small amount of sediment was found in each of the twolower wells and in the aft lower well                                                   a small clotning type safety pin andthe head                  of a small dural rivet were also found. No evidence of distortionor fresh                  scoring was found, on either of tnese oojects.. The wells measured1|" deep                  and tie bayonet extension of the aft lower bayonet measured l-7A6nthe allowable extension being 1-3/8 to If inchesThe reclining back of seat Jo. 33, located adjacent to the left cabin willjust forward of the main entrance door (occupied by tne missing passenger) was * found collapsed rearward with its lower structure broken, the headrest missingand tne upholstery at the upper outooard corner torn. The seat belt wasintact and unbucKled. Tnc inboara am rests of three aisle seats (Nos. 10, - 11 - 15 and 2$) located along the aisle between the lavatory and the mam entrance door were also damaged. No repairs were made to N 1030V at Rio de Janeiro, and the aircraft was ferried to Miami on July 31, 195>2, where it was met by a Board investigator. Security was established over the aircraft and its log books and the investi- gation was continued on that date Physical findings of the preceding in- vestigation were confirmed at ?nani. Examination of the main cabin door and door frame revealed some minor distortions and a somewhat deteriorated door frame sponge rubber seal. (On July 1, 1952, 26 days before the accident, a new seal had been installed in the door frame.) The lower door hinge which was distorted had been removed at Rio de Janeiro so that the door could be closed for the ferry flight. This door was opened, closed and locked numerous tunes to determine if the locking mechanism or any of its safety devices were malfunctioning None was found. The door warning light system was also checked several times; no evidence of malfunctioning was foundc Kfter repair of the door hinge and sealing arrangement and the proper adjusting of the tension of the lower cable at hiami, the door was re-instalied in N 1030V. Flight tests were then conducted which disclosed air leakage around the door. Recheck of the sealing arrangement revealed that air was leaking between two sheet metal members, part of the door frame. This ad- mitted air to the space behind the door frame seal. aIt leaking into this space would tend to loosen the bond which holds the door frame seals It was determined that the metal screws holding the door frame trim angle were loose, and tightening them stopped the leak. --- 12 ---Board investigators reviewed all maintenance records applicable to themain cabin door of N 1030V for a 30-day period prior to the accident. Theserecords disclosed three instances of door leakage due to deterioration of therubber seal* In addition, the company submitted to the Board a B-377 doorwarning summary of instances of trouble and corrective action taken on all ofits Boeings for the six months period. During this period there were 26 re-ported instances of trouble involving the                                                              aircrafts four exterior doors,including faulty door frame seals and leakage around the mam cabin door.K majority of these instances, however, indicated trouble m the door warninglight system* There have been many instances of false warnings to the crewn the cockpit, but in each case when the light came on, it was the                                                      duty ofthe flight engineer to check the locking mechanisms of the exterior                                                      doorsBecause of these rather frequent false warnings, it became practice                                                      toignore the warning light, after a check had been madeThe flight engineer testified that he had received three weeks                                      trainingon the B-377 at the Boeing factory during February 1?U9= This course ineluded a brief familiarization with the general locking mechanism of theaircrafts exterior doors Later                                                 he was given the usual flight trainingcourse of about 30 hours0 One of                                                 his overall auties was checking these doorsif the door warning light came on                                                in the cockpit* The flight engineer hadapproximately 2,607 hours on the B-377The captain testified that he attended the companys school for B-377familiarization at New York for approximately six weeks in 1950* The courseincluded discussion and inspection of the doors, their locking mechanismand their warning devices - 13 - Analysis , As explained, there was no malfunctioning of trie door or any of its locking mechanisms or safety devices, and it is thus clear that the accident was caused by the crews failure to recognize the hazard of an incompletely locked cabin door, due to jamming by a loosened door frame seal. None of tne previously mentioned safety locking devices can function -uiless the latching mechanism and the door handle are in the fully closed pos..tion. The crew should have been aware of the danger Because of three fully independent warnings of imminent trouble. First was the warning light that remained on* Second was the noise of pressurized air escaping around the top of the door. And third, and possibly the most important, -.'as the fact that the door handle never was in a position to more than partially extend the locking bolts (bayonets). The first of these three warnings, the light, was plain ana continuous. The second, the escaping air, was brought to the flignt crews attention by the purser. The thira, trje door handles position, should in itself have been enough to indicate to the flight engineer what was due to happen. In fact, the flight engineers act of attempting to force further the door handle during pressunzea flight could well have precipitated tne blow-out. the companys operating manual plainly states that in the event of door % leakage the door handle shall not be touched because any attempt to adjust it during pressurized flight can only lead to further opaiing of the door# The fli$t engineer was aware of this specification but ignored it# Further- more, when he first chocked the door handle on the ground and found afteropening and reclosing the door, that the handle would still not go to its locked (horizontal) position, he could readily have learned whether themechanism was working properly by reopening the door and turning the doorhandle to the closed position while observing the travel of the locking boltsThis he                         lid not doThe flight practice of ignoring a door warning light, despite frequentfalse warnings, is certainly subject to criticism.light was a true warning.The deep indentation in the door's upper rear corner and slight dis-placement of the adjacent portion of the doors seal mated exactly with theslight depression in the door frame*                                           In other words, when the door wasclosed, the two depressions abutted as if they had both been caused by thewedging of the same object.These two depressions are marked on attachment A. Their positionsrelative to the missing portion of the door seal suggested strongly that itwas a loosened and sagging door frame seal that had jammed at that point.Accordingly, tests were conducted with a similar obstruction placed inthe same position. It was found that under this condition, the door handlecould be rotated only to approximately the same position from the horizontalas was described by the flight engineer.Both pursers on the two previous legs of this flight testified as todifficulty in fully closing tne door* This might well, and probably does,mean that the door frame seal was becoming loose several flight hours beforethe accident but not, of course, to the extent necessary to prevent fulllocking of the doorAs previously described, N 1030V was test flown after all repairs nadbeen made to the cabin door and its frame                                                            Leakage still occurred and it wasSee our selection of aviatioon documents at RareAviation.com - 15 - found that this was caused by the loose metal screws behind the dcor frame lining. I his condition caused the eventual loosening of the door frame seal. These loose screws had not been discovered during the door and frame repairs and probably had been loose for aa appreciable period of time. Thus, because the condition that allowed this leakage had been pro- gressive, it is highly probable that the seal sagged from the frame after the aircrafts door was opened following the landing at Rio do Janeiro. No company employee reported a sagging seal, but its position, fren the extreme top of the door frame, could allow a slight sag to remain unnoticed. The most probable reason for the door opening during flight is as follows^ The door frame seal became loose neo along the top of the frame during the flngh from Port of Spain to Rio de Janeiro. But, as the door remained closed, it wa* held in its proper position. It sagged whan the aoor was opened, and this sagging remained unnoticed while the aircraft was made ready for tne next leg of the flight. Upon closing the door the sagging seal jammed, creating the narks shown on Attachment A, and presenting the door from being fully closed* Although there is a marked difference of opinion between the flight engineer and purser as to how far the door handle was turned, it is self evident that it was turned only far enough to engage the tapered ends of the bolts in their receptacles. Cabin pressure exerted an increasing force on the door. This foifce reached a magnitude sufficient, under normal vibration conditions in flight, to expel the tapered ends of the bolts frem their receptacles and back into tne door edge, whereupon the door opened violently under the impetus of a force of several tons. Outgoir^ a^ir carried a^ay the sagging portion of the frame seal also as shown on Attachment A. * As one result of this accident, the carrier is installir^ indicators onthe B-377 four latching mechanisms that now visible through the corner - 16 -windows of the cabin door. These indicators, extending to the windows, willbe conspicuously colored --- red for open, green for locked^ Pending thisinstallation the latching mechanisms themselves have been painted conspicuously to allow their positions to be more readily determined. The moving capportion of the pressure switch has been marked for alignment. These marksare visible through the pressure switch window.Also, the carrier is in the process of changing the warning lightsystem on its B-377s This change will involve placing a warning light ateach of the four exterior doors. The single cockpit warning light willremain to indicate that any of the four doors are improperly locked, and theindividual door lights will allow immediate isolation of the trouble.All of the carriers B-377s were immediately inspected for loose doorframe trim screws and the condition of door frame seals, and this inspectionwill be continuous as directed by a service bulletin issued by the company to all its stations.^/A few days after this accident the company, following conferences withthe Civil Aeronautics Administration, issued all personnel concerned adirective to follow all procedures published and in effect at                                    the time ofthe accident, applicable to the main cabin door of the B-377.                                       Theseincluded:1.        No take-off permitted if door warning light                  is on unless cause of warning is definitelyestablished        as warning system malfunction.2         No take-off        permitted unless bayonet locks are observed to        be m fully extended position and door handle        is in full locked position-4/ Jill other U. S, operators of B-377 equipment were likewise alerted. - - 17 -3. ham door secure inspection to be made before take-off and again after pressurized by pilotor engineer personnel properly safeguarded to determine that door handle bayonets and pressure locks are properly engaged. The same directive carried these additional items which were not in effect at the time of the accident: If door warning comes on or air leak is noted at main entrance door in pressurized flight, the following action is required: (a) Move passengers fren two left-hand seats just forward of main entrance door and have one flight crew member guard area at all times at safe distance and conduct any desirable investigation with proper safeguards from safe distance, (b)  If door handle or bayonets not in place, as soon as conditions permit descend to safe altitude, depressurize, and properly engage door locks* Pressurized flight may be resumed if lock can be engaged* 5* Use guard rope in main door area at all tines  6*< Thorough maintenance investigation any flight item on main door warning system at next station to insure maxirnun dependability of warning system; also strict adherence to established door rigging and inspection pro- cedures at routine services. On September 15, 19523 the ccnpany issued an Operations Inforaation Bulletin for insertion in all B-377 operations manuals* It included the A above directives and the following: "RESPONSIBILITY FOR DOOR INSPECTION: % le When there is one flight engineer aboard, the Captain shall be responsible to assign a qualified  crew member to make the after pressurization check covered in Item (4) above.5/ For the purposes of this report "Item 4 above" is in substance items 3 and 4 above. --- 18 -*2 The flight engineer shall be responsible far all ground, checks of all natches for security, therethere are two flight engineers on board, the flight engineer shall be responsible for all air inspections and checks of all hatches for con- dition and security. Where there is one flight engineer on board, the flight engineer shall be responsible for all air checks of all hatches for security after inspection by a qualified pilot has initiated a report of any abnormal con- dition or malfunctioning of any door engaging mechanism. The procedure outlined in the first section of this memorandum must be followed for all these inspections and checks.Although the flight engineer had been given a brief indoctrination ofthe B-377 exterior doors and their locking devices at the Boeing factoryapparently no continuing program of familiarization of such devices had beeninstituted by the company for either the flight crew or the cabin attendantsHowever, such a course has now been established and is in effect for allpertinent crew membersThe captains formal schooling in connection with the doors had beenmore than two years before the accident, and there is no record of his havingreceived any refamiliarization on the suboectOf course, the B-377 operations manual which is required to be aboardthe aircraft and is available to all flight crew members contains full infomation relative to doors and their operation.Pan American World Airways temporarily suspended both Captain Fly andFlight Engineer Knight until the investigation of this accident was completedThe flight engineer was later discharged by the company, and the captain re-turned to flight status in his former capacityThe Civil Aeronautics Administration took the following action as aresult of this accident - 19 - 1. Admonished the company by letter to make all B-377 cabin attendants familiar with the locking of the cabin door sufficiently to allow than to recognize a hazardous condition, and to make flight crew members familiar with door mechanisms and safety devices, 2. Reprimanded the captain by letter for con- tinuing the flight with a pressurized cabin without taking further precautionary measures and ignoring danger warnings, but not for wilful disregard for the safety of the flight. A copy of this letter has been placed in the captain's airman certificate file, CAA, Washington, D. 0, 3 The hiami office of the CAA recommended to the Administrator, Washington, D. C,, that the airman certificate of the flight engineer be suspended for three months subject to its being renewed upon his passing a written, oral and practical examination administered by an authorized agent of the CAA. Findings On the basis of all available evidence the Board finds that:  1< The carrier, the aircraft and the crew were properly certificated. 2.  When the flight reached an altitude of 12,000 feet, the cabin pressure  differential was 4*1 psi. 3.  The main cabin door blew open in flight because it was not fully locked. 4* This unsafe condition was not recognized by the flight engineer. 5* The captain failed to evaluate properly the warnings and continued flight under pressurized conditions* 6. A passenger seated nearest the door was blown through it and lost at- sea; none of the other occupants was injured. 7o Considerable damage occurred throughout the interior of the cabin 8. Following the decompression the flight at once descended and returnedto Rio de Janeiro - 20 -The door locking mechanist and all its associated safety deviceswere inspected and found to be functioning normally.10,  The door frame seal loosened and sagged sufficiently to jam and pre- vent fully locking the dqor prior to take-off, resulting m a substantial air4 leak during pressurized flight. 11.  Later tests revealed an air leakage due to loose metal screws in thedoor frame trim angle12.                                         This leakage eventually deteriorated the bond between the                             loor frameseal and liner*13.                                         The company did not maintain an adequate training program relative toexterior door mechanisms and safety devices on the B->377> so that hazardousconditions could be avoided.Probable CauseThe Board determines that the probable causes of thus accident were(a) the flight engineer's failure to recognize an unsafe condition of thecabin door despite three completely separate warnings of that condition; and(b) the captain's action in continuing flight while pressurised despite the several warnings that the mam cabin door was not properly locked.BY THE CIVIL AERONAUTICS/s/ DONALD We NYROP/s/ OSWALD RYANA/         JOSH LEE/s/ JOSEPH P. ADAMS/s/ CHaN GURNEY SUPPLEhENTAL DATA ** --- *-**                                        aw Special Investigation The Civil Aeronautics Board was notified of this accident at 1600 GMT, July 2?, 1952, at Rio de Janeiro, Brazil, and an investigation was immediately initiated m accordance with the provisions of Section 702 (a)(2) of the Civil Aeronautics Act of 1938, as amended. In connection with the investiga- tion, depositions were taken and other documents including photographs were made a part of the record at Washington, D. C.; hiami, Florida; ano at Jamaica, Long Island, New York, in lieu of a public hearing. Air Carrier Pan American World Airways, Inc., is a New York corporation, having its mam offices at 135 Bast 42nd Street, hew 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 Rio de Janeiro, Brazil, South America, Flight Personnel Captain George Lafayette Fly, age 42, was employed by Pan American World Airways on October 2, 1939. He was the holder of a valid airman certificate with an airline transport rating for single and multi-engine lana and sea aircraft, 0-6600 horsepower. Captain Fly had a total of 10,729 flying hours, of which 1,574 hours were in 3-377 aircraft, He had received his last CAA physical examination on Hay 28, 1952. Flight Engineer J. D                            Knight, age 38, was employed by Pan American World Airways on March 1, 1942                                               He was the holder of a valid airman certificatefor a flight engineer, and an aircraft mechanic and engine mechanic ratings. Mr. Knight had a total of 7,7h4 flying hours, of wmeh 2,607 hours were inB-377 aircraft. His last GAA physical examination was on June 6, 1952.The Aircraft N 1030V, a Boeing B-377 Stratocruiser, was owned and operated byPan American World Airways and was currently certificated by the CivilAeronautics Administration. It had a total of 7,885 flying hours and was equipped with Pratt & Whitney R---4380, TSBJ---O engines and Hamilton Standard2426 propellers AlTACEiENT MA* - Exhibit UB-1 1. Hear Rio de Janeiro, Srazil, 7/27/52                 Fa.w. 3-377 h 1030V Showing door as found (axceot upholstering along ton of ooor urich was pullec loose by investigators). iOTts Indentation of coor ana soor seal at "A". Frame seal missing between arrows. Slight inoentatxon ci frame at ,|5". '.oie that inside door nanale is norisontal (loc.ced ocsiiion) ana tnat ?~i~i locking bolts are fully extende1, oeronstratmg th.ju tne locking -er-nan r.qpi uas ?unctioning norially. SA-                                                                                                                                                       File No. 1-0091CIVIL AERONAUTICS BOARDACCIDENT INVESTIGATION REPORTAdopted: July 15, 195U                                                                                                                 Released: July 19, 195LPAN AMERICAN WORLD AIRWAYS, INC. - BETWEEN HONOLULU, T. H., AND WAKE ISLAND DECEMBER 6, 1953The AccidentThe No, 1+ engine and propeller of N 9091+7, a Pan American World Airways Boeing 377, tore from the aircraft after little warning at 1236,1/December 6,1953* The flight was about halfway to Wake Island from Honolulu, T. H., cruising at its assigned altitude of 10,000 feet. Control was regained after losing considerable altitude and the flight diverted to Johnston Island. None of the 35 passengers and seven crew members was injured.Flight 0ne/05 departed San Francisco International Airport at 201+8, December                                                      5, 1953, on a scheduled flight to Tokyo. The first intermediate stop was                                                      to be Honolulu, and the second Wake Island.The                                                           flight arrived Honolulu at 0613, December 6. No malfunctions of the aircraft                                                      were experienced between San Francisco and Honolulu.                                     Except for routine servicing and inspections during the stop at Honolulu                                                                                          no work was needed                                                        Flight crews were changed.The flight departed Honolulu International Airport at 081+7 under an aonroved                                                      ItR-type flight plan but in Visual Flight Rules weather. There were 35 passengers and a crew consisting of Captain E. G. Kelley, First Officer L. B. Newby, Second Officer F. M. Kelley, Flight Engineer W. J. Foster, Purser M. J. Finney, Stewardess P. Lux and Steward E. E. Moore. Gross weight of the aircraft at takeoff was 139,MO pounds (maximum allowable 11+h,900 pounds). The load was properly distributed with relation to center of gravity limits.The flight was routine until 1235, three hours and forty-eight minutes after departure, when the crew felt an unusual vibration. At the time, the flight was in clear weather and smooth air. The vibration built up rapidly and within a minute culminated in an explosive noise and violent jolt. The aircraft went out of control in a right descending turn accompanied by violent buffeting. The flight was at 20.1+ North Latitude and 17iiU West Longitude, almost exactly halfway between Honolulu and Wake. The nearest land was Johnston Island, about 350 nautical miles to the southeast.Captain Kelley had left the cockpit semetime earlier. First Officer Newby who was occupying the right seat noted the vibration. He immediately 1/ All times referred to herein are Greenwich Civil Time and based on the 2b-hour clock. ordered all propeller spinners checked, disconnected the automatic pilot, and flew the aircraft manually. Control surface boosters were not turned on after the automatic pilot was disconnected. The flight engineer and second officer (who was navigating) checked from B compartment, forward of the cabin, but did not observe any of the engines running roughly or propeller spinners wobbling. The flight engineer returned to his station and attempted to detect the trouble; none of the engine instilments showed abnormal read- ings and he was unable to isolate the source of the vibration.At the first sign of abnormal operation the captain hurried back to the cockpit. As he reoccupied the left seat, he glanced ever his shoulder atthe flight engineers panel to see if he could detect the trouble. No. h engine and propeller fell away at that moment; simultaneously, violent buffeting began.The steward had come forward to report unusual vibration in the galley and saw a flash of fire as No. h engine left; he and the second officer called to the flight engineer that No. h was gone.The buffeting continued during the diving turn to the right. The master fire warning light came on and the fire warning bell sounded; there was nofurther evidence of fire thereafter, so CO? was not used. Power was reduced on the left engines. Full left aileron and rudder tabs were rolled in. Wing flaps were extended about 15 degrees to reduce buffeting, but were found in- effective; they were therefore retracted. The combined efforts of both pilots were used to apply full left aileron and rudder, but the right wing would not come up. At this time, ditching appeared imminent.In an effort to raise the right wing and bring the aircraft under control, the captain ordered fuel dumped from No. U tank. The aircraft continued to lose altitude while 2,500 pounds of fuel were dumped, and control was even- tually regained. Altitude was temporarily stabilized at 3,700 feet, then the aircraft again settled slowly until the power and air speed combination was found which would arrest descent and still permit control with the least buffeting. Heading was controllable within 20 degrees at 1L5 knots indicated air speed and descent was checked at 2,300 feet.The first officer had been able to transmit a "Mayday" shortly after the engine and propeller tore out. A little later, before descent was arrested, he reported their position to Honolulu and advised the purser over interphone to prepare the passengers for a water landing. Steps had already been taken by the cabin attendants, in accordance with company emergency procedures, to assist passengers in preparation for ditching.From time to time, Honolulu was advised of progress in coping with the emergency. At 12h5 the flight advised Honolulu they were attempting to reach Johnston Island.The Search and Rescue organization was imediately alerted after the "Mayday." Two aircraft were dispatched from Honolulu and an Air Force air-craft left Johnston Island. Interception was made at lhl8 by the Air Force aircraft approximately IhO miles northwest of Johnston Island. Surface craft in the vicinity of Johnston Island were alerted as the flight approached.The Fli^it was able to maintain 2,300 feet to Johnston Island and landed at 1^32, two hours and 6 minutes after the engine and propeller fell freeInvestigationWeather was not a factor in this accident. The forecast was for clear weather throughout, with scattered cumulus along the course well below flight level. The crew stated that no adverse weather was encountered, and turbu- lence was light.Since there was a malfunction in the No. b power package, followed very quickly by failure which caused the engine and propeller to rip out, the investigation was centered on ascertaining the nature of the malfunction and reason for the failure.Investigation by the                                Board and testimony given by engineers fran Pan American, Boeing Airplane                           Company, and Hamilton Standard Propeller Division disclosed that loss of the engine and propeller could have been caused by (1) failure of the engine mount, (2) sudden stoppage or seizure of the engi (3) an unbalanced or otherwise defective propeller, or (h) a combination ofthese. Since the engine and propeller fell in deep water and could not be recovered, there was no opportunity to examine them.During investigation of the first possibility above, it was found in examination of the No. b engine mount that the--top portion of the engine mount ring was missing                          Laboratory examination of the remainder of the ring, an attach fitting, and a portion of a buckled support tube did not reveal any evidence of fatigue failure. This study showed that all fracturesapparently had been caused by loads in excess of the design strength. From examination of these pertinent parts and the engine mount in general, it appeared that separation of the engine from the aircraft was downward and to the right.Loss of No. b engine exposed to the air stream the large flat plate area of the fire wall to which the oil cooler remained attached. This created drag and buffeting of such proportions that control could not be regained until dumping of fuel from the No. b wing tank made it possible to raise the wing.The fuselage skin on the right side above the lounge door was damaged by a piece of engine cowling. The skin was abraded, with a slight amount of buckling. There was a triangular tear approximately eight square inches in area at Station 806, just forward of the window above the door. Three circumferential members and three stringers in this area were damaged, but there was no structural failure. There were two small tears in the top skin of the right wing at Stations 213 and 219; the tears were 1-1/b and 2-3/b inches long.Regarding the second possibility --- that of sudden engine stoppage or seizure --- investigation disclosed that there have been no known cases ofthis type aircraft in which an engine has torn from an aircraft, even at high r.p.m., as a result of sudden stoppage.Investigation of the third possibility, that of propeller failure, revealed that the engine mount on this aircraft showed several points of similarity with another mount from which No. 1 engine was wrenched out in flight. In this comparative case, a B-377 of another carrier over Glenview, Illinois, on January 25, 1950, the engine and propeller were recovered andit was found that a propeller blade failure had occurred, causing the engine to fall free. In another case, a Pan American B-377 landed at New York International Airport on March 29, 1951, after unusual vibration was ex- perienced in flight. After landing the No. 1 engine was found drooped in the nacelle and No. 1 propeller had lost 12-1/2 inches of one blade. There have been two other B-377 cases in which the engine and propeller were not recovered for study, but their engine mounts showed points of similarity with the mount in the Glenview incident.Pan American officials stated that the hollow blade steel propeller, which has been installed on all B-377 *s, has given good service and their maintenance and infection procedures have followed practices recommended by the manufacturer. From time to time, the propeller manufacturer and the carrier have felt it desirable to adopt more exacting inspection and blade rework procedures. Following this accident, in cooperation with Hamilton Standard, Pan American instituted more stringent procedures for operation, inspection, and maintenance of the hollow blade steel propellers installed on its B-377 aircraft.The hollow blade steel propeller, by the nature of its construction, is susceptible to external damage and therefore requires exacting inspection and maintenance.A nickel-plated hollow steel blade for B-377 aircraft, manufactured by Hamilton Standard, was certificated by the CM'for air carrier operation onSeptember ill, 1953* This blade, rtiile slightly heavier owing to the plating, has shewn promise in being considerably less subject to damage by foreign objects such as stones and debris. It is of the same design as the unplated blade, but improvements have been incorporated in it to lessen or eliminate other difficulties, such as corrosion-Presently, there is no solid-type propeller blade available for B-377 aircraft.The corrpany, the aircraft, and the crew were currently certificated. AnalysisAs the engine and propeller could not be recovered for study, it was not possible to determine beyond question the cause of malfunction and failure; however, investigation of previous accidents of this type and the eviderce in this instance indicate strong possibility of propeller blade fai1nre. This was based on the character and duration of vibration, study of the engine mount, and the probability that engine seizure or engine mount failure could be eliminated as causes.It has previously been noted that Pan American adopted more stringent requirements following this accident for operation, inspection, and maintenance of the hollow blade steel propellers. In addition to this, the carrier decided to retire the tinplated hollow steel blades in favor of replacement with the nickel-plated type, since it was felt that the new blade would give better service. This program of replacement started early in 195U, and the carrier anticipates that replacement on its B-377 fleet will be                                                            accomplished during 1955* In the meantime, the improved procedures relative                                                             to the hollow steel blade will remain in effect.Pan American has also been testing several vibration pickup units, the purpose of which is to give early warning of excessive vibration in a powerplant. This permits the flight engineer or pilot to identify the malfunction' ing engine or propeller and to take it out of operation by feathering the propeller before serious damage occurs. The results of this testing program have proved promising and the' carrier plans early installation of such units on its aircraft. A similar unit to detect unusual amounts of vibration in the power plant is being developed by Hamilton Standard.The Board wishes to commend the crew for the efficient manner in which they handled a most difficult situation.2/ The immediate transmittal of dis-tress signals, the preparation of passengers for possible ditching, and the dumping of fuel, as needed, were all accomplished with praiseworthy precisionFindingsOn                             the basis of all available evidence                               the Board finds that:The carrier, the aircraft, and the                           crew were "currently certificatedThe gross takeoff weight of the aircraft upon departure from Honolulu was less                             than the maximum allowable and the load was properly distributed.3. Flight 0ne/05 to Wake Island was routine until 1235, three hours and forty-eight minutes after departure from Honolulu, when an unusual vibration was noted.1|. Vibration built up rapidly and within the next minute, No. h engine and propeller tore from the aircraft while the flight was at its assigned altitude of 10,000 feet.5. Control of the aircraft was temporarily lost during a right descend- ing turn, acconpanied by violent buffeting.6. Dumping of fuel from No. U tank permitted control to be regained after losing 7,700 feet altitude.7. The flight diverted to Johnston Island, landing at 1532, two hours and 56 minutes after loss of the engine and propeller.8. Intercept aircraft were dispatched by the Search and Rescue organi zation and one escorted the flight into Johnston Island.2/ Captain E. G. Kelley; First Officer L. B. Newby; Second Officer F. M. Kelley; Flight Engineer W. J. Foster; Purser M. J. Finney; Stewardess P. Lux; and Steward E. E. Moore. Probable Cause The Board determines that the probable cause of this accident was a propeller blade failure resulting in an unbalanced condition which tore No. h engine from the mount. By the Civil Aeronautics Boards/s/ CHAN GURNEY /a/ HARMAR D. PENNY/s/ OSWALD RYANA/                 j       SI       3 LEEA/ JOSEPH P. ADAMS SUPPLEMENTAL                                    DATAInvestigation and HearinThe Civil Aeronautics Board was promptly notified of the accident on the morning of December 6, 1953. An investigation was inmediately initiated in accordance with the provisions of Section 702 (a)(2) of the Civil Aeronautics Act of 1938, as amended.                                In lieu of a public hearing, a Special Investigationwas ordered and depositions taken at San Francisco, California (January 11-13 1954), Seattle, Washington (January 18, 1954), Washington, D. C. (February 12 1954), and Windsor Locks, Connecticut (February 17-18, 1954).Air CarrierPan American World Airways, Inc., is a New York corporation with its main offices in New York, New York. Headquarters for the Pacific-Alaska Division are at San Francisco International Airport. The corporation 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 airended. These certificates authorize the carrier to engage in air transportation between various points in the United States and foreign countries.Flight PersonnelCaptain Elmer G. Kelley, age 34, was enployed by Pan American World Airways as a pilot in 1941. He held a valid airman certificate with an air transport rating and type rating for several aircraft, including the B-377. Captain Kelley had a total of 6,763 flying hours at the time of landing at Johnston Island, of which 534 were in B-377 equipment. He received his latest route check on June 12, 1953, an emergency equipment recheck on October 13, 1953, and his last CAA physical examination on November 30, 1953First Officer Luther B. Newby, age 39, was employed by Pan American World Airways on January 11, 1942. He had served as a captain for six of his 12 years with Pan American and as a first officer in the Pacific-Alaska Division since 1948, because of pilot seniority requirements. Mr. Newby possessed a valid airman certificate with an air transport rating and a type rating for B-377 aircraft. At the time of landing at Johnston Island, he had 11,564 flying hours, of which 3,180 were acquired on B-377 aircraft. His latest physical examination was given on August 17, 1953, and his latest emergency equipment recheck on August 14, 1953Second Officer Frank M. Kelley, age 33, was employed by Pan American World Airways in 1945. He held a valid airman certificate with an air trans-port rating and a flight navigator's certificate. Mr. Kelley had accumulated 1,066 hours, of which 285 were on B-377 aircraft, at the time of the Johnston Island landing. His last CAA physical examination was given on April 28, 1953 and latest emergency equipment recheck on November 18, 1953.Flight Engineer William J. Foster, age 42, was employed by Pan American World Airways in 1934 and had served as a flight engineer since 1936. He held a valid flight engineer certificate and had accumulated 4,224 hours in B-377 aircraft. He received his last CAA physical examination on November 25, 1953, and his latest emergency equipment recheck on May 1, 1953. Purser Margaret J. Finney was employed by Pan American World Airways in April 191*6. She received her latest emergency equipment recheck prior to the accident on July 28, 1953. Stewardess Patricia Lux received an emergency equipment recheck on June 17, 1953. Steward Eugene E. Moore was employed by Pan American World Airwsys in 1951, and received his latest emergency equipment recheck on June 23, 1953. The crew departed San Francisco at 201*7, December 1*, 1953, and arrived at Honolulu at 0619, December 5. After a rest period of 26 hours, they departed on Flight 0ne/05 at 081*7, December 6. The Aircraft N 9091*7, a Boeing 377, serial number 15963, was owned and operated by Pan American World Airways and was currently certificated by the Civil Aeronautics Administration. At the time it landed at Johnston Island, it had almost 10,023 hours, of which nearly 872 hours had been acquired since its last periodic (No. 5) service. It was equipped with Pratt and Whitney Wasp Major B-6 engines and Hamilton Standard 21*260-1*3 propellers. When No. 1* engine left the aircraft, it had a total of 6,760 hours, of which 615 hours had been accumulated since overhaul. No. 1* propeller had three Hamilton Standard 2J17F3-8W and one 2J17H3-8W blades. An F-3 (short cuff) blade was replaced at Pan Americans propeller overhaul shop, San Francisco, on September 17, 1953, with the H-3 (long cuff) blade, which had been reworked by the manufacturer. The replacement blade had about 2,1*00 hours and the other three about 6,800 hours when the change was madej the propeller was balanced before installation on the aircraft. /COPYPan American World Airways System Chrysler Building, 136 East 42nd Street, New York 17, N.Y.August 3 1, 1954. Mr. C.B. Probert, Inspector of Accidents Department of Industry and Commerce Kildare Street Dublin, Ireland.Dear Sir'This is with furth     er reference to your letter dated July 31, 1954 regarding     the accident to DC6B aircraft N-653IC on February 15,     1954.Our review indicates that we have no further evidence in connection with this accident which would be of anymaterial use in connection with your investigation. However, we would like to state that your tentative conclusion as to the second contributory factory seems to us to be questionable. The pilot in question had received his Type Rating for DC6B aircraft prior to the flight in question and could have served as Captain. However, he was serving as co-pilot for familiarization in accordance with the Companys procedures before taking over as Captain in command. His transitional training was in full compliance with the Civil Air Regulations which govern the                            operation. Under the circumstances, you may find it appropriate to revise your tentative conclusion. Very truly yours,(Signed) John C. Pirie, Assistant General Course File No. 1-0052 CIVIL AERONAUTICS BOARDAIRCRAFT ACCIDENT REPORTADOPTED: February 10, 1965                                                   RELEASED: February 16, 1965PAN AMERICAN WORLD AIRWAYS BOEING 707-139, N779PAJOHN F. KENNEDY INTERNATIONAL AIRPORT JAMAICA, NEW YORK APRIL 7, 1964 SYNOPSISA Pan American World Airways, Inc., Boeing 707-139, N779PA, operating as Flight 212 from San Juan, Puerto Rico to New York, New York, touched down on the far end of runway 4R at John F. Kennedy International Airport and during landing roll overran the runway and came to rest m Thurston Basin on April 7, 1964, at 2303 e.s.t.The aircraft sustained major structural damage, there was no fire. Of the one hundred and forty-five occupants including nine crew members thirty-three receivedminor injuries and seven serious injuries. There were no fatalities. The Board determines that the probable cause of this accident was the captain !s deviation from the glide slope during an ILS approach resulting in a touchdown on the runway at a point and speed which precluded stopping the aircraft on the remain- ing runway.Investigation Pan American World Airways, Inc., Flight 212 (PAA 212) was a regularly sched-uled passenger flight from San Juan, Puerto Rico, to John F. Kennedy International Airport (JFK), Jamaica, New York. The flight originated at San Juan but because of adverse weather upon arrival in the New York area, it was diverted to Dulles Inter- national Airport, Chantilly, Virginia. With subsequent improvement in the New York weather, the flight departed Dulles International Airport for JFK Airport. Following an Instrument Landing System (ILS) approach, touchdown was made on runway 4R. The aircraft ran off the far end of the runway and came to rest in Thurston Basin sustaining major structural damage. There were no fatalities among the 145 persons aboard the aircraft. However, 33 received minor and 7 serious in- juries.The crew involved m this accident departed Miami, Florida, m N779PA at 1152 e.s.t.l/ April 7, 1964, as the assigned crew of PAA Flight 455, a regularly scned- uled passenger flight between Miami and San Juan. This flight was routine and landed at San Juan at 1355.1/ All times herein are eastern standard based on the 24-hour clock. At San Juan the flight crew received a weather briefing from U.S. Weather Bureau personnel which included the terminal forecasts issued by the U.S. WeatherBureau offices at JFK Airport, Boston, Detroit, and Washington, D. C., for a 24- hour period beginning at 1200 After making other preflight preparations, the same crew departed San Juan m N779PA at 1514 for JFK Airport operating as Pan American World Airways Flight 212 (PAA 212). The flight was conducted in accordance with, an Instr