1974_美国_AAR7411.pdf

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AIRCRAFT ACCIDENT REPORT: AIRCRAFT POOL LEASING CORPORATION, LOCKHEED SUPER CONSTELLATION, L-1049H, N6917C, MIAMI, FLORIDA, DECEMBER 15, 1973

National Transportation Safety Board Washington, D. C.

11 September 1974

DISTRIBUTED BY:

NTIS

National Technical Information Service U. S. DEPARTMENT OF COMMERCE

TECHNICA

ITIE DAPE DSC 040 4/10

15. Supplementary Notes

This report does not contain any new recommendations.

16. Abstract

At 2353 e.s.t. on December 15, 1973, an Aircraft Pool Leasing Corporation's Lockheed Super Constellation L-1049H, which was operating as a cargo carrier, crashed after takeoff from runway 9L of the Miami International Airport, Miami, Florida. The aircraft struck the ground 1,25 miles east of the airport and destroyed several homes, automobiles, and other property. The aircraft's occupants--three crewmembers--and six persons on the ground were killed. Two others were injured slightly. The aircraft was destroyed by impact and fire.

The National Transportation Safety Board determines that the probable cause of this accident was overrotation of the aircraft at lift-off resulting in flight in the aerodynamic region of reversed command, near the stall regime, and at too low an altitude to effect recovery. The reason for the aircraft's entering this adverse flight condition could not be determined. Factors which may have contributed to the accident include: (a) Improper cargo loading, (b) a rearward movement of unsecured cargo resulting in a center of gravity shift aft of the allowable limit, and (c) deficient crew coordination.

As the result of this accident, the Safety Board has made several recommendations to the Administrator of the Federal Aviation Administration.

17. Key Words

Takeoff accident, aircraft loading, weight and e.g., operations under Subpart D, 14 CFR 91, Flight in reversed command, crewnumber qualifications, medical certification.

18. Distribution Statement

This document is available to the public through the National Technical Information Service, Springfield, Virginia 22151

1. Security Classification

(of this report) UNCLASSIFIED

1. Security Classification

(of this page) UNCLASSIFIED

1. No. of Pages

32

1. Price
2. 75

NTSB Form 1765.2 (11/70)

Reproduced by NATIONAL TECHNICAL INFORMATION SERVICE US Department of Commerce Springheld, VA 22151

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PRICES SUBJECT TO CHANGE

TABLE OF CONTENTS

Appendices

Preceding page blank

File No. 3-3313

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20591

AIRCRAFT ACCIDENT REPORT

Adopted: September 11, 1974

AIRCRAFT POOL LEASING CORPORATION

LOCKHEED SUPER CONSTELLATION

L-1049H, N6917C

ML-MI, FLORIDA DECEMBER 15, 1973

SYNOPSIS

At 2353 e.s.t. on December 15, 1973, an Aircraft Pool Leasing Corporation's Lockheed Super Constellation L-1049H, which was operating as a cargo carrier, crashed after takeoff from runway 9L of the Miami International Airport, Miami, Florida. The aircraft struck the ground 1.25 miles east of the airport and destroyed several homes, automobiles, and other property. The aircraft's occupants--three crewmembers--and six persons on the ground were killed. Two others were injured slightly. The aircraft was destroyed by impact and fire.

The National Transportation Safety Board determines that the probable cause of this accident was overrotation of the aircraft at lift-off resulting in flight in the aerodynamic region of reversed command, near the stall regime, and at too low an altitude to effect recovery. The reasons for the aircraft's entering this adverse flight condition could not be determined. Factors which may have contributed to the accident include: (a) Improper cargo loading, (b) a rearward movement of unecured cargo resulting in a shift of the center of gravity aft of the allowable limit, and (c) deficient crew coordination.

As the result of this accident, the Safety Board has made several recommendations to the Administrator of the Federal Aviation Administration (FAA).

1. INVESTIGATION

1.1 History of the Flight

On December 15, 1973, Aircraft Pool Leasing Corporation's Lockheed Super Constellation L-1049H, N6917C, was on a nonscheduled cargo flight from Miami International Airport, Miami, Florida, to Maiquitia Airport, Caracas, Venezuela. The cargo load consisted of Christmas trees from Canada; there were no passengers.

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On the evening of December 14, 1973, N6917C was taxed to the loading ramp of a freight company in the northwest area of the airport. At 0700, 1/ December 15, 1973, loading began and was completed at 1230. The freight loading supervisor stated that the main cabin was completely filled with trees. Bundles of trees were also loaded into the forward and aft belly compartments.

At 1329:20, Miami International Flight Service Station (IFSS) received an instrument flight rules (IFR) flight plan for N6917C. The proposed departure time, as filed with Miami Air Route Traffic Control Center (ARTTC) was 1415. This time was subsequently amended by the crew to 2200, because of the need to replace the aircraft's batteries, which were missing when the flight engineer made his routine walk-around checks.

After replacement batteries were purchased, charged, and installed in the aircraft, the three-member crew began preparing for departure.

At 2256, after overcoming some difficulty starting the engines, the flight contacted Marl Ground Control (GC) and requested taxi clearance. N6917C was cleared to taxi to runway 9L and an en route clearance was given to the crew at 2307. The aircraft proceeded to the ramp area adjacent to runway 9L and remained there until 2322. The crew then advised the tower that they would like to return to the ramp and requested that their flight plan be held as they expected a delay of only 15 to 20 minutes. A witness at the freight terminal stated that when the aircraft returned, the crew requested some assistance because they couldn't properly close the crew compartment door. Something was sturk in the door roller track. The witness stated, "I got a screwdriver out of my car and gave it to somebody who took it up to the copilot, and whatever it was that was lodged in the roller, he got it out."

At 2341:45, the crew reestablished radio contact with Miami GC, and the flight was cleared to taxi back to runway 9L. Witnesses stated that as the aircraft taxied from the runway ramp, the No. 1 engine stopped; however, it was restarted immediate.

At 2350:30, the flight advised the local controller that the flight was ready to roll. The controller asked if the flight was " . . . going from the intersection." The flight replied, "Seven Charlie affirmative." The flight was cleared for takeoff on runway 9L and advised of, ". . . traffic 4 miles out for the runway." At 2351, the crew acknowledged, "One seven, Charlie."

Upon clearance, a rolius takeoff was started. According to tower controllers, the aircraft became airborne abruptly 4,800 feet from the start of the takeoff, and it assumed an unusually nose-high attitudes.

1. All times herein are eastern standard, based on the 24-hour clock.

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According to two of the controllers, N6917C's attitude was 20° to 30° noseup shortly after the aircraft became airborne.

The controllers agreed that the aircraft attained a maximum altitude of 100 to 120 feet as it continued its climbout. They also agreed that the landing gear was down until the aircraft passed the end of the runway. It then appeared to retract. As the flight continued eastward, controllers lost visual contact with it because of a hangar that obstructed their view. The hangar is about 120 feet high. The tower cab supervisor recalled that the aircraft was losing altitude as it disappeared behind the hangar.

At 2352:55, the local controller cleared N6917C to contact Miami departure control and 10 seconds later, the flight acknowledged, 'One seven Charlie.'

At 2353:25, a two-word transmission, "One Charlie," was heard on the local frequency of 118.3 MHz. At 2353:35, an aircraft on final approach to runway 9L reported to the tower that "some kind of smoke ball went up." Tower concolliers also observed a flash and a ball of smoke at about the same time.

The aircraft crashed 1,25 miles east of the airport. After striking high tension wires and a tree, the aircraft crashed into a parking lot, after which it collided with several homes and other property before stopping.

The weather was clear and the visibility was 10 miles. Many persons observed the aircraft at various places along the flightpath. Most of the witnesses interviewed were aeronautically qualified with either pilot or maintenance backgrounds, or both. Many of them were located north and east of the takeoff runway and adjacent to it. The majority of witnessesaz stated that the aircraft did not exceed an altitude of 100 to 200 feet and that most of the time it maintained an extremely nose-high attitude. Some witnessesz stated that the aircraft was flying very slowly, ". . . near a stall." Eleven witnessesz stated that the engines were either not producing full power or were malfunctioning in some manner. Most witnesses who were in a position to observe the aircraft in its final moments of flight, stated that the left wing was down and that the tail was very low; some of these reported that engine sound decreased or ceased just before impact.

One witness, with an aircraft maintenance background, stated: "The aircraft continued down the runway and then it appeared to me that the power was reduced, and I thought the captain was going to abort, but he did not. Power was again applied, and the aircraft broke ground about even with Eastern's 1011 hangar. It raised to about 100 feet. Not any more than 100 feet was reached, if that. I believe about the time he

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reached the airport fence his anti-collision light on top of the fuselage was in full view to me, indicating that the aircraft had dropped its tail and was in a severe nose-up position. At the same time, it started to sink. It started to raise momentarily as if it were going to recover and then sank out of sight. . . .

1.2 Injuries to Persons

1.3 Damage to Aircraft

The aircraft was destroyed by impact and postimpact fire.

1.4 Other Damage

Four homes, seven automobiles, and a motorcycle were destroyed by impact and fire. Several homes were damaged slightly.

1.5 Crew Information

The captain and the first officer were certified properly for the flight. The captain was qualified in the aircraft. The first officer did not satisfy the second-in-command qualifications in 14 CFR 61.55. The flight: engineer lacked recency of experience in the aircraft and obtained a first-class medical certificate by withholding information concerning his past medical history. (See Appendix B.)

1.6 Aircraft Information

The aircraft was certified and maintained according to Federal Aviation Administration (FAA) requirements. (See Appendix C.)

The L-1049H is certified for a maximum takeoff weight of 142,100 pounds, a maximum allowable landing weight of 114,500 pounds, and a maximum zero fuel weight of 100,500 pounds. The center of gravity (c.g.) limits are between 18 percent and 32 percent mean aerodynamic chord (MAC). On July 5, 1973, N6917C was recertified with a basic empty weight of 72,542 pounds at a c.g. of 13.9 percent MAC.

The aircraft was loaded with 666 bundles of Christmas trees. Report-edly, 621 bundles were loaded in the cabin, 15 in the forward baggage compartment, and 30 in the aft baggaga compartment. The bundles did not contain the same number of trees and, therefore, were not the same size and weight. According to the freight loading supervisor, those bundles loaded into the main cargo compartment through the rear cargo loading

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door were stacked longitudinally from the forward bulkhead to the rear of the aircraft. The trees were stacked from wall to wall and from floor to ceiling, without leaving a passageway to the rear of the aircraft. The loading supervisor testified that the butt ends of the trees faced the forward end of the airplane, and additional trees were overlapped until the true bundles reached the ceiling. This loading pattern continued to the rear of the aircraft until the aircraft was completely filled. One witness reported that a small area directly opposite the door was left unloaded. The methods of securing cargo prescribed in 14 CFR 91.203 were not used, and the loading supervisor did not receive any guidance with regard to load distribution. He stated that the original intent was to load all of the trees on hand into the aircraft. When it was apparent that this could not be done, he was told to put an many on 18 possible.

The lack of a weight and balance manifest hampered efforts to determine the correct weight and distribution of the load aboard N6917C. Based on the Canadian export declaration, the average weight of each bundle was 33.5 pounds. Therefore, the total cargo weight was about 22,311 pounds. Randomly selected trees bundles at the accident scene weighed an average of 42 pounds per bundle. An average weight of 42 pounds would have resulted in a total cargo weight of 27,972 pounds. The average weight of the bundles that were not loaded aboard the aircraft was 51 pounds per bundle. These trees, however, had been wet down after the aircraft had been loaded. An average weight of 51 pounds would have resulted in a total cargo weight of 33,966 pounds.

N6917 was fueled with 3,300 gallons of 115/145 octane aviation gasoline. According to the flight engineer's log, which was recovered from the wreckage, there were 1,500 gallons in the Nos. 1 and 4 main tanks, and 650 gallons in the Nos. 2 and 3 main tanks. Based on these figures, N6917C was carrying 4,300 gallons of fuel at takeoff.

Based on the available information, the Lockheed California Company calculated the aircraft's weight and c.g. for the various tree-bundle weights. It was assumed that the bundles were uniformly distributed throughout the aircraft. The table that follows shows the results of those calculations.

The effect of an aft shift of the cargo on the aircraft's c.g. was also calculated. For each inch average shift of the total load the effect would be:

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1. 14 percent MAC for 51-pound bundles
2. 12 percent MAC for 42-pound bundles
3. 10 percent MAC for 33-pound bundles

A document recovered from the cockpit showed two figures, apparently in the captain's handwriting: A $V_1$ of 103 kn. and a $V_2$ of 118 Kn. These figures correspond to a takeoff gross weight of between 130,000 pounds and 132,500 pounds, respectively.

A freelance copilot, who flies regularly in the Miami area and who had flown N6917C, said that restraining straps or cargo nets are not generally used to secure cargo. He also stated that generally the c.g. determinations are made by "guesstimate" and accordingly, the pilots who fly the cargoliners use the full runway length for takeoff. They normally accelerate the aircraft slowly and make shallow liftoff rotations and climbouts to prevent load shifts.

According to information obtained during the inquiry from airmen who had flown N6917C, the landing gear safety solenoid had to be overridden manually in order to raise the gear handle. They also stated that the throttle friction locks on the pilot's quadrant and on the flight engineer's panel were defective and would not hold the throttles properly.

1.7 Meteorological Information

The surface weather observation recorded by the National Weather Service at Miami International Airport immediately following the accident was as follows:

2356 - Clear, visibility-10 miles, temperature-67°F., dew point-57°F., wind-180° at 5 kn., altimeter setting-30,00 in.

1.8 Aids to Navigation

Not applicable.

1.9 Communications

No difficulty was reported with communications between the flight and air traffic control.

1.10 Aerodrome and Ground Facilities

The Miami International Airport is located 9 miles NW of Miami at geographic coordinates 25° 47' 35'N, latitude and 80° 17' 10" W, longitude. The airport elevation is 9 feet, and has three paved runways. Runway 9L/27K, which is 10,500 feet long and 200 feet wide, is the longest of the three. The full length of the runway is grooved for 90 feet on each side of the centerline. High intensity runway lights serve the runway.

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1.11 Flight Recorders

No flight data or cockpit voice recorders were installed in this aircraft nor were they required.

1.12 Aircraft wreckage

1.12.1 Structures

The wreckage was distributed in a residential area on NW 30th Street between NW 32nd and NW 31st Avenues. The wreckage was confined to an area about 530 feet long and 60 feet wide. (See Appendix D.) Gouge marks showed that the left wing and the left horizontal stabilizer struck the ground simultaneously; they were consistent with a left wing-down attitude of about 40° and a fuselage attitude of about 25° noseup.

There was no evidence of in-flight structural failure, fire, or explosion.

All structural separation resulted from the impact; there was no evidence of in-flight malfunction or failure of the primary structure or of any of the flight control surfaces or systems.

The forward fuselage between FS-122 and FS-481 was separated from the aft main fuselage section. This section included the captain's, first officer's and flight engineer's seats. All of the seats were attached to the floor structure. The captain's and first officer's seats were twisted to the left and in a forward direction. This entire fuselage section was not damaged by fire.

Each of the four engines had separated from its attaching structure. The left and right wings had separated from the fuselage; both were partially consumed by the ground fire. The left main landing gear had separated from its wing attaching structure, and the right main gear was retracted and attached to the remaining portion of the right wing. Some cargo was still inside this section of the fuselage, and no cargo tiedown ropes, nets, or webbing were found.

One flap panel from the right wing was recovered. The flap panel was still attached to the wing-to-fuselage filet area. The panel was wrinkled and had been damaged by heat; the flap was partially extended. The distance between the forward panel of the flap roller slide and centerline of the flap roller bolt was 33.25 in. This measurement was set on a similar model aircraft; the setting corresponded to a takeoff position of 60-percent flap extension.

1. 12. 2 Systems

The windshield area was removed $^{1}$uring rescue operations; therefore, controls, switches, and some instrument readings may have been altered.

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The damaged elevator flight control boost unit was in the manual position, but the cockpit lever was in the boost "on" position. The elevator flight control boost unit is operated by cables which had failed as the result of tension overloads. The unit was examined extensively on and off the aircraft. There was no evidence of a preimpact failure or malfunction.

The hydraulic cross-over valve control switch was in the normal position. Hydraulic pressure for both primary and secondary systems was indicated by gauge readings. The bulb for primary hydraulic pressure warning contained a stretched filament.

The rudder boost was located in the tail wreckage. It was mounted in position and cables and hydraulic lines were attached. There were no apparent leaks in the hydraulic lines or fittings.

The engine start switch was found in the No. 2 engine position and the propeller reversing light bulb filament for the No. 2 propeller was stretched.

There was no evidence of a pitot-static system failure or malfunction. The pitot tube at the lower right side of the fuselage was un-damaged, and the inlet was clear.

1.12.3 Powerplants

The remains of the 4 engine assemblies showed no evidence of in-flight fire. Disassembly and inspection of the examinable accessories and components of the four engines disclosed no preexing discrepancies. Examination of the four engines showed that: (1) The removed spark plugs were in normal condition and evidenced minimal wear; (2) the walls of the removed cyiinders throughout the area of piston travel were comparatively smooth; (3) the exposed pistons did not bear any indications of distress or markings suggestive of engine overspeed; (4) the intake and exhaust valves and valve seats were in good condition with no indications of burning or pitting noted. Borescope examination of the remaining intact cylinders confirmed similar observations.

Cylinder removal also demonstrated that: (1) The internal articulating components of the power section were intact and were not damaged; (2) the piston rings moved freely within their respective frooves, except where the individual pistons were heat damaged.

Examination of the supercharger sections of the four engines revealed that: (1) The power recovery turbine crank-shaft drive gear coupling for the Nos. 1, 2, and 4 engines was broken in a typical torsion mode at the drive splines, while the No. 3 engine drive gear coupling was intact; (2) the power recovery turbines did not indicate any preexisting

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distress; and (3) the interral operating components of the No. 2 and No. 3 engines' supercharger were intact, and the impeller clutches functioned normally.

The leading edges of most of the blades of each propeller exhibited rotational gouge and screpe marks at random locations. Most of the blade-bending pattern was in a forward direction. Impact markings showed that the propeller blades were symmetrically positioned or the low pitch stop (140) on impact. The racka located within the electric head of the Nos. 1, 3, and 4 engines constant speed control assemblies (propeller governor) were in the takeoff position. The rack position of the No. 2 engine constant speed control assembly could not be determined because of separation of the gear and pinion assembly. No mechanical discrepancies or indications of contamination were found within these assemblies.

The low pitch stop assembly of the No. 2 propeller was functionally tested. At an applied pressure of 800 psi, the piston did not move. Normally, the piston moves at 290 psi. Leakage of the assembly was 5 oz/min, where a maximum allowable leakage is 2 oz/min. It was found that an "O" ring (Manufacturer's Part No. 79413) was worn completely away at one location with the remainder of the "O" ring uniformly worn to a threadlike size.

1.13 Medical and Pathological Information

Post-mortem examination of the six persons who were killed on the ground revealed that they died of severe burns and smoke inhalation. Four of these victims were pronounced dead at the scene, another died the following morning, and the sixth victim died 3 days after the accident.

Post-mortem examinations of the crewmembers revealed that they died instantly because of severe impact trauma. No evidence of an incapacitating disease was found during the examination. However, during the investigation of their medical backgrounds, it was discovered that the flight engineer had a history of alcoholism. He had been a resident of various rehabilitation centers, including one where he was medically diagnosed as a "severe chronic alcoholic" and as having "alcohol epilepsy." He had a history of convulsions beginning in 1966. This information was not made known to the FAA Aviation Medical Examiners (AME's) when the applicant applied for his medical certificate.

The flight engineer's November 16, 1973, First-Class Medical Certificate was issued by an AME in Miami, Florida, who had previously issued him Second-Class Medical Certificates on November 9, 1970, and on January 22, 1973. Between these dates, the flight engineer attempted to renew his medical certificate in the Netherlands on December 3, 1971.

According to the AIE in The Netherlands, who wrote a letter to the FAA Aeromedical Certification Branch, at Oklahoma City, Oklahoma, the

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flight engineer's hearing and vision were inadequate. Additionally, the AME wrote that the flight engineer was not mentally fit, or was ". . . under the influence of drugs or alcohol." He marked him abnormal in the psychiatric block of the examination form. He then gave the flight engineer a letter of denial because he could not issue the Second-Class Medical Certificate for which the flight engineer had applied.

The AME said that he had presigned the medical certificate before denial and that later he found that the certificate, the letter of denial, and the AME file copy of the application had disappeared.

The completed Second-Class Medical Certificate, dated December 3, 1971, was found among the flight engineer's belongings.

The FAA replied to the doctor in The Netherlands on January 10, 1972, and stated that the computer had been "flagged" for subsequent applications submitted by the flight engineer. However, there was no further correspondence relative to this matter in the flight engineer's file.

Toxicological studies performed on the crewmembers revealed the following levels of carboxyhemoglobin (COHb): Captain's chest blood-23 percent carboxyhemoglobin (COHb), femoral vein blood-21 percent, first officer's heart blood-slight trace, flight engineer's heart blood trace. The captain, reportedly, was a heavy cigarette smoker. He had also been around operating aircraft all day.

Reference to medical publications indicates that a 21 vo 23 percent level of COHb in the blood could adversely affect a person's vision, coordination, and central nervous system functions, including judgment. Additionally, the flight engineer's blood contained .58 mg, percent of meprobamate, a tranquilizing drug. The Physicians' Desk Reference to Pharmaceutical Specialties and Biologicals mentions, in part, the following regarding meprobamate: ", . . 0.5-2.0 mg. percent represents the usual blood level range of meprobamate after therapeutic doses." FAA publication AC 91.11-1, "Guide to Drug Hazards in Aviation Medicine," indicates that meprobamate may have the following undesirable effects in aviation: "Tremulousness, muscular relaxation, sleepiness, nausea, depression, allergic reactions, leukopedia, thrombocytophenia, intolerance to alcohol, withdrawal symptoms."

i. 14 Fire

At 235, the Miami tower notified the Irport fire watch officer that an aircraft was down about 1 mile east of runway 9L. At 2356, the City of Miami Fire Department received a call that an aircraft had crashed and was on fire. Firefighting equipment arrived on the scene at 0001.

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The rescue personnel used power saws and hydraulically operated "jaws" to gain access to the cockpit area so that the bodies of three crewmembers could be removed. According to rescue personnel, the three crewmembers were found in their seats with their seatbets fastened.

1.15 Survival Aspects

This was a nonsurvivable accident.

1:16 Tests and Research

The Lockheed California Company prepared a performance study for the Safety Board using as a basic reference the FAA-approved Flight Manual and Lockheed aerodynamic data. The calculations were based on a gross slight of 134,520 pounds, a takeoff roll of 4,800 feet, wing flaps in the takeoff position, and the existing atmospheric conditions. In addition, Lockheed assumed an angle of attack of 110, the angle at which stall buffet would start. The Lockheed study states, in part:

"For the assumed weight, the 1049H Flight Manual gives a takeoff safety speed $V_2$ equal to 121 KCAS, and a minimum control speed with one engine inoperative (propelier windmilling) equal to 91 KCAS. The calculated flightpaths assume takeoff at $V_2$, accelerating to $V_2+6$ KCAS at 50 feet height above the runway, and climabout from 50 feet height at $V_2+6$ KCAS. For the assumed N6917C angle of attack of 11° an airspeed of 100 KCAS results. This 100 KCAS flight, on the back side of the power and thrust curve, results in about 35 percent less excess thrust available for climb than would have been available at the 10 speed of $V_2+6$ KCAS."

according to Lockheed calculations, the 4,800-feet ground roll would have required only 9,800 brake horsepower (bhp). Theoretically, use of maximum takeoff power (13,384 bhp) would have resulted in a 2,200-foot ground roll.

Flight on the backside of the power curve refers to the regime of flight speeds below the speed for minimum required power setting. Any decrease in speed below this point results in an increase in the power required. Therefore, a higher power setting is required to maintain a lower airopeed, while holding altitude. The regime of flight on the backside of the power curve is also called the region of reversed command, to distinguish it from normal command (the front side of the power curve), where a decrease in airspeed results in a corresponding decrease in power required.

During the public hearing, a Lockheed representative stated that, "The aft center of gravity limit is reasonably close to the neutral point." He defined neutral stability as a c.g. location rearward of the allowable c.g. aft limit where "the motion of the aircraft would not react

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significantly to a motion displacing the aircraft. If you went further behind there would be a tendency for the nose to continue down or to continue up, as the case might be." He also indicated that at an aft c.g. location of 37 to 38 percent MAC, "the aircraft would probably need more elevator control than is available under that situation."

The aircraft stalls at an angle of attack between 14° and 16°, Stall buffet may occur between angles of 90 and 13°,

Hamilton Standard was requested to provide estimated blade angles based on the ambient conditions prevailing at the time of the accident. These computations were based on the type of powerplants that were on N6917C. Estimated blade angles with the propeller operating at takeoff power: and at the below listed airspeeds were:

1.17 Other Information

The aircraft was owned by Aircraft Pool Leasing Corporation located in Miami, Florida. It was certified and maintained under the provisions of 14 CFR 91, Subpart D.

Initial contract negotiations for the flight were conducted between the freight forwarding agent and the flightcrew, and between the forward- tug agent and the aircraft owner. These agreements indicated that the forwarding agent was the operator. However, the lease between the for- warding agent and the owner was rejected by representatives of the forward- ing agent, and a waiver was drawn up and signed by a representative of the aircraft owner. This waiver indicated that the aircraft owner was the operator.

In view of the questions surrounding the validity of these contracts, and the potential safety implications, the Safety Board made recommendations to the Administrator. (Appendix E)

2. ANALYSIS AND CONCLUSIONS

2.1 Analysis

The aircraft was certified and maintained according to FAA regulations; however, the following maintenance discreancies had not been corrected: The landing gear safety solenoid, the t-rottle friction

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locks, and the leaking low-pitch stop assembly of the No. 2 propeller. All applicable airworthiness directives had been complied with.

There was no evidence of an in-flight fire or explosion, structural failure, flight control malfunction, or systems failure. Although the elevator boost unit was in the manual or boost "off" position in the wreckage, the position was consistent with the impact damage it sustained. In addition, the boost lever in the cockpit was in the "on" position.

The primary hydraulic system's low-pressure warning light had a stretched filament, which suggests that it was illuminated at impact. It was probably triggered when the left wing struck the first building and destroyed the primary system engine pumps and lines. Hydraulic pressure gauges reflected that there had been system pressure before impact. Since the landing gear was retracted after lift-off, the secondary system was operable. Since it automatically backs up the primary, if the primary system had failed, the functioning secondary system would have powered the controls. Thus, the elevator control boost unit did not malfunction because of hydraulic power loss. In addition, teardown and testing revealed there was no evidence of a preimpact malfunction nor did maintenance records indicate a history of elevator control problems. On the basis of these findings, hydraulic system failures were discounted as a causal factor.

Examination and testing of the engines, propellers, and their pertinent accessories and components showed that they were operating normally at impact. The blades of the four propellers were found on the low pitch stop. There are three possible explanations for this finding: (1) Extremely low airspeed at impact; (2) the engines were not operating and the propellers were windmilling on the low pitch stop; (3) the engines were operating with the engine power levers pulled back to the "Idle" position.

Based on witnesses' observations, the damage pattern of the propellers, and the symmetrical blade angles at impact, the power levers must have been retarded just before impact. This is further substantiated by the fact that even at low airspeeds, the propeller blade angles should be at 18°, or higher, at takeoff power settings.

The leak found in the low-pitch stop assembly of the No. 2 propeller indicates that this propeller could not have been placed into the reverse position. Since the stretched filament of the associated reversing light bulb suggests that this light was illuminated, the light was probably triggered during the impact sequence.

Since there is no physical evidence of engine problems, the variations in engine sounds are attributed to power management procedures or

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creeping throttles. Therefore, the mechanical condition of the engines and propellers was not related to the direct cause of the accident.

The consensus of the witnesses' statements was that the aircraft rctated abruptly to an unusually high pitch attitude and that the short duration level flight after takeoff was essentially flown in a similar attitude and at a slow speed.

Performance data indicate that with the aircraft flying in the in-cipient portion of reverse command, there would have been no difficulty in climbing. Instead, N6917C ceased to climb after it reached an altitude of about 120 feet. Therefore, the observed attitude of the airplane and its performance during its short flight lead directly to the conclusion that it was flying deeply in the area of reversed command and near the stall regime. In this area, drag at relatively low speeds is significantly higher than drag at higher speeds during normal takeoff. As a result, a point may be reached at which power available is less than the power required to overcome the drag and maintain level flight. To fly out of this area, drag must be reduced by changing pitch attitude, power must be added, altitude must be sacrificed, or a combination of these corrections must occur. Under some conditions, these corrections cannot be made, or are not practical, and a descent or a stall may be imminent. Such is believed to have occurred in the case of N6917C.

The Safety Board was unable to determine the reason or reasons for the aircraft's entering this adverse flight condition. However, the in-quiry disclosed several areas, any one or any combination of which would have led to this situation. Those which appear to be most pertinent are:

1. Improper loading or cargo shift, or both.

1. Deficient crew coordination.

1. Improper Cargo Loading and/or Cargo Shift

The possibility that the cargo may have been improperly loaded and, consequently, shifted, thereby causing the aircraft to initially assume and maintain a critical attitude behind the power curve was investigated in detail. Considerable credence was given to the estimated gross weight based on the captain's $V_1$ and $V_2$ calculations. This gross weight -- between 13C, JCO and 132,500 pounds -- falls midway between the gross weights calculated based on average cargo bundle weights of 42 and 51 pounds. Therefore, the performance data that were based on a grot) weight of 134,524 pounds provide a reasonable basis for a discussion of the c.g. aspects.

Most of the evidence concerning the aircraft's loading was inconclusive, and in some cases, contradictory. Although the performance data

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were based on a uniform distribution of the tree bundlas, it is more likely that the density of the load increased toward the rear of the aircraft, when it became apparent that closer stecking of the bundles was needed to accommodate all of them. Therefore, the actual c.g. may have been aft of the calculated c.g. of 29.7 percent MAC, which was based on a uniform distribution of 51-pound bundles. Possibly, N6917C was misloaded to the degree that its $\pi \sim 5$, was at or beyond the aft c.g. before taxing out. This fact alone would help explain the abrupt, nose-high vocation.

Although it could not be determined to what extent the load may have shifted during the takeoff acceleration, the witness' statement which indicated that a small area near the aft cargo door was left unloaded, suggests that there was at least some room for a cargo shift. Therefore, the Safety Board concludes that accelerative forces, in combination with a vibrating metal floor, could only have had an aggravating effect on the c.g. location of the compressible and unsecureal cargo. Even if the c.g. was 29.7 percent MAC, an average cargo shift of only 16 inches would be needed to reach the geour-down aft c.g. limit of 32 percent MAC. A 60-inch shift would be needed to reach an aft c.g. of 38 percent MAC where flight would be extremely critical since there would not be sufficient elevator control. available. Between the latter c.g. and the aft c.g. limit lies the neutral point, a c.g. position where the airplane would exhibit neutral static stability.

Based on the observed performance of the aircraft and the circumstances surrounding the loading of the cargo, the Safety Board believes that a critical aft c.g. may have contributed to the accident.

2. Deficient Crew Coordination

Deficient crew coordination pertains to the flight management of the aircraft as related to the overall control of the f'ight by the captain, the manipulation of the various flight and powerplay controls, and the combination of both of these with the possible actions of one or more partially incapacitated or unqualified crewmembers.

Possibly, the flaps were retracted prematurely, causing the aircraft to rotate to a high angle of attack to compensate for the lift which was lost by the retracting flaps. The factor that rules against in-flight flap retraction was the observation that a steeper-than-normal attitude started at ground level rather than at some point in flight.

If the takeoff was started with the flaps retracted, a 4,800-foot ground roll at normal takeoff power could have accelerated the aircraft to a velocity high enough to compensate for lift loss by a no-flap configuration. When airborne without the added drag of flaps, a well-balanced aircraft could have accelerated easily in a normal clubout. These factors rule out a no-flap takeoff. Further, the flaps were found in the takeoff position.

• 16 -

Loss of power because of throttle mismanagement is also a possible contributing factor. Unintentional reduction of power to the extent that flight could not be maintained could have resulted from incapacitation of the flight engineer. Power reduction could also occur subtly if the crewmembers failed to monitor the throttle friction lock.

A factor that could have caused the crewmembers' attention to be mis-directed was the necessity to override the landing gear safety solenoid manually in order to retract the gear. This operation required two hands, since the gear handle is on the aft, lower part of the center pedestal, and the solenoid is recessed inside a hole on the lower right side of the conter pedestal. An inexperienced and unqualified first officer might have needed assistance to retract the gear.

Witnesses reported that the landing gear was raised late in the take-off and the landing gear was found in the full "up" position in the wreck-age. The flight engineer would have had difficulty reaching either the gear handle or the solenoid. Therefore, the captain or the first officer could have been occupied raising the landing gear during the critical initial portion of the flight. This fact, coupled with the loose throttle friction, may have set the stage for the throttles to creep back during the takeoff.

In each of the preceding situations, the captain's unexplainable high COHb level, the physiological condition of the flight engineer, and the inexperience of the first officer may have complicated events at a critical time and, therefore, contributed to the accident.

2.2 Conclusions

a. Findings

1. The aircraft was certified and maintained in accordance with 14 CFR 91; however, there were some discrepancies that had not been corrected.

1. There was no evidence of preimpact structural or flight control failure, fire, or powerplant failure.

1. The captain and the first officer were certified properly; however, only the captain was qualified for the flight.

1. The first officer did not meet the requirements of 14 CFR 91,213.

1. The flight engineer lacked recency of experience as required by 14 CFR 91,211 and was not medically qualified for the flight.

· 17 ·

1. The captain's blood contained sufficient COHb to have adversely influenced his vision, coordination, and judgment.

1. The flight engineer's blood contained sufficient meprobamate to have caused detrimental effects on his performance.

1. The landing gear safety solenoid had to be depressed manually in order to raise the gear handle, and the throttle friction lock on the pilot's quadrant and at the flight engineer's station would not secure the throttles adequately.

1. The wing flaps were in the takeoff position at the time of the crash.

1. The gross weight of the airplane was below the maximum allowable weight of 142,100 pounds.

1. Cargo restraining devices were not used.

1. Based on available aircraft loading information, the center of gravity could have been at or aft of the aft limit when loading was completed.

1. There was no evidence that the cargo was so tightly packed that it could not shift.

1. The aircraft exhibited critical stability characteristics, as evidenced by the brupt rotation at lift-off.

1. The aircraft was rotated and flown in the area of reverse command, near the stall regime.

b. Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was overrotation of the aircraft at lift-off, resulting in flight in the aerodynamic region of reversed command, near the stall regime, and at too low an altitude to effect recovery. The reason for the aircraft's entering this adverse flight condition could not be determined. Factors which may have contributed to the accident included: (a) Improper cargo loading, (b) a rearward movement of unsecured cargo resulting in a center of gravity shift aft of the allowable limit, and (c) deficient crew coordination.

• 13 -

3. RECOMMUNDATIONS

As result of the accident, the Safety Board on September 11, 1974, issued Safety Recommendations A-74-62 through A-74-64 to the Administrator, FAA. On October 2, 1974, the Safety Board issued to the Administrator, FAA, an additional recommendation, A-74-84. Copies of these recommendations are included in Appendix E.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

/s/ JOHN H. REED Chairman

/s/ LOJIS M. THAYER Member

/s/ ISAREL A. BURGESS Member

/s/ WILLIAM R. HALEY Member

FRANCIS H. McADAMS, Member, did not participate in the adoption of this report.

September 11, 1974

• 19 -

APPENDIX A

INVESTIGATION AND HEARING

1. Investiation

The Board was notified of the accident at 0017 on December 16, 1973, and an investigation team went immediately to the scene. Working groups were established for operations, weather, air traffic control, witnesses, structures, systems, powerplants, human factors, and maintenance records.

Parties to the investigation included the Federal Aviation Administration, the Lockheed California Company, and the Dade County Aviation Department. A representative of Aircraft Pool Leasing Corporation later joined the powerplants group.

2. Public Hearing

A public hearing was held at the Everglades Hotel, Miami, Florida, February 5 through February 7, 1974. Parties to the hearing were: the Federal Aviation Administration, Dade County Aviation Department, aircraft, Pool Leasing Corporation, and Paulssen and Guice, Ltd.

• 20 -

APPENDIX B

CREW INFORMATION

Captain William C. Fox

Captain William C. Fox, 48, held FAA Transport Pilot Certificate No, 1055729, airplane multiengine land, commercial privileges airplane single engine land, Douglas DC-3/4, Convair 240/340/440, and Lockheed Constellation. Mr. Fox also held an instrument and flight instructor certificate that was issued on December 4, 1970, and super-seded an airman certificate issued July 1967. The latest rating expired December 31, 1972. His first-class medical certificate was issued on November November 16, 1973. The certificate noted that the holder shall wear correcting glasses while exercising the privileges of his airman's certificate. (A pair of half-frame glasses with corrective lenses was found in the left section of the pilot compartment, and another pair of corrective lens glasses was found in the captain's flight kit.)

His logbook showed 11,550 flight-hours, including 7,355 hours as pilot-in-command. His total flying time in Lockheed Constellation type aircraft was 1,087.9 hours.

Captain Fox was a freelance pilot. His actual rest period before the flight could not be determined. He arrived at the airport at about 0700 o. the day of the accident, and most of his time during the morning and afternoon was spent waiting for the aircraft to be loaded and prepared for flight.

First Officer Jeffrey H. Flanders

First Officer Jeffrey H. Flanders, 30, held Commercial Pilot Certificate No. 1734038 with ratings for airplane single and multiengine law and sea and instruments. He also held a flight instructor certificate with ratings for airplanes and instruments. His first-class medical certificate, with no limitations, was issued January 24, 1973.

His estimated total flying time was 2,500 hours, including 1,050 hours of flight instruction time and 650 hours of seaplane flying. Mr. Flanders was a freelance pilot.

There was no record that he had Lockheed Constellation experience before the accident. An air carrier employment application, dated January 16, 1973, revealed that Mr. Flanders had listed 5 hours of "Prop Four Engine Total Flight Time," flown in a Sikorsky SV44A. Following the accident, a friend of Mr. Flanders said that Mr. Flanders and Captain Fox had spent some time in the aircraft (N6917C) for familiarization on the night before the accident.

• 21 -

APPENDIX B

Mr. Flanders reportedly departed his residence on December 15, 1973, at approximately 0700.

Flight Engineer Arthur A, Kimball

Flight Engineer Arthur A. Kimball, 59, held Flight Engineer Certificate No. 1139732 with ratings for reciprocating engine aircraft. The certificate was issued February 24, 1969, Mr. Kimball's flight logbook showed that this certificate was a renewal and that the original license had been issued in 1949. He held a first-class medical certificate with the limitation that the holder shall wear correcting glasses while exercising the privileges of his airman's certificate. The last entry in his logbook was made on February 26, 1973; however, the flight times had not been totaled since March 1966. At that time his total flight time was 6,044 hours.

Mr. Kimball's flight log summary started in 1954 and recorded flight time each year to 1961. There was no record for the years 1962 and 1963. The summary was not completed beyond June 1966, although title headings were entered for the years 1967 and 1969. There were no entries from October 27, 1966, to August 2, 1967, and from December 24, 1970, to December 14, 1972. Flights recorded in Lockheed Constellation aircraft were made on December 9, 10, and 11, 1969, and totaled 11 hours, 55 minutes. The memoranda section of the flight logbook recorded a lockheed Constellation flight to South America on September 3, 1970, for a total trip time of 71 hours 30 minutes.

He arrived at the airport at about 0700 on the day of the accident.

• 22 -

APPENDIX C

AIRCRAFT INFORMATION

Aircraft N6917C, a Lockheed Super Constellation L1049H, Serial No. 4815, was manufactured by Lockheed Corporation, Burbank, California, in 1957, under FAA Aircraft Specification 6A5. A Certificate of Airworthiness Form ACA-136a, was issued by the FAA on April 8, 1957, to Lockheed Aircraft Corporation, the registered owner.

On April 11, 1957, a Standard Certificate of Airworthiness, Form ACA-1362, was issued by the FAA LA-223/32, to Flying Tiger Line, Inc.

In September 1967, the aircraft was placed in storage in Kingman, Arizona, where it remained until February 10, 1970.

On January 26, 1970, Mr. F. George Areces, President, Trademark Leasors, Inc., San Juan, Puerto Rico, submitted an application for the registration of N6917C.

On June 30, 1970, the FAA Aircraft Registration Eligibility, Identification, and Activity Report indicated that the aircraft was owned by North. Slope Supply Company, Inc.

On September 10, 1970, a weight and balance certification was accomplished on the aircraft for Aerofletes Internacionales, S.A. "AFISA". The registration at that time was for HP 526 which is a Republic of Panama registration and is the first indication of a registration change from U. S. registry.

In July 1971, Trademark Leasors, Inc., Rio Piedras, Puerto Rico, Malling Address-Acrofletes Internacionales, Aptdo 6270, Zona 5, submitted an Application for Certificate of Airworthiness to the Government of Panama for HP 526. The application was approved by the Republic of Panama on July 16, 1971. Aircraft HP-526 (N6917C) remained under the Panamanian registry until the owner, Mr. F. George Areces, sold the aircraft to Aircraft Pool Leasing Corporation, P. O. Box 176, MIAD, MIami, Florida 33148, on July 6, 1973. The conveyance was filed with the FAA Aircraft Registry on July 12, 1973, and was recorded on July 30, 1973.

The last major inspection was a combined annual and 100-hour recertification which was performed on August 16, 1973, at Aeroborne Enterprises, Inc., Opa Locka, Florida. The inspection was performed in accordance with 14 CFR 91, Subpart D.

At the time of the inspection, the aircraft had accumulated 28,905 hours, of which 3,800:15 hours were flown since overhaul. During this inspection, the altimeter and static system checks were accomplished as required by 14 CFR 91,170.

• 23 -

APPENDIX C

On August 27, 1973, the aircraft was inspected by the FAA and issued a Standard Airworthiness Certificate.

The aircraft was maintained in accordance with an aircraft inspection manual approved by the FAA on July 13, 1973.

According to the records, all airworthiness directives were complied with.

The aircraft was equipped with four Wright Aeronautical Division Turbo Compound Type 3350, Model 988TC18EA3 engines and four Hamilton Standard 43H60 propellers. Powerplants identification and overhaul data as of August 16, 1973, are as follow:

EN INES

PROPELLERS

PROPELLER BLADE SERIAL NUMBURS

The No. 3 propeller serial number is based upon the aircraft records listing. The hub did not have any identifying numbers legitle to confirm the serial number. The records, however, have watched all four of the engines and the other three propellers.

24

〔图〕AEIIAI YEW LOCKING EASI\n 〔图〕、N45443HOUSE4039HOUSENO.31433332J1HOUSNO253145●2230◆xIMPACTCRATERHOUSNO.113172COF CREIE BLOCKAAlLFIRE DAMAGENtHOUSE NC.3

LEGEND

1. 7°x10° piece of Propelfer Blade

1. Broken piece of 2nd Navigotional Light Lens

1. Tree with tops shreaded

1. Perking wheel pumper

1. Fagments of red Navigationation: Light Lem

1. Piece of left wing outboard structure

J. Piece of left outboard wing fuel cell with filler neck

1. Section of Left Stabilizer with left vertices $^{1}$ Fin and Rudder attached

1. 4"x8" piece of Propeller Blade

1. Section of Propeler Blade

1. Major portion of left wing and accorries consumed by fire

1. Left wing Flon Linege

1. Left Cutboa & Main Landing G.r. Door

1. Section of Propeller Blade - No. 2 Propeller

1. Breaken Utility Pole

1. Left Inboard Main Landing Gear Door

1. No. 1 Engine and Propeller

1. Section of Proce'ier Blade

1. All Fuselage Tail Cone

1. Distributor

1. Left Main Landing Group

1. Proceller | 111

1. Wing Flap Panel

1. Section of Inloard Wing Skin

1. Broken Utility Pole

1. Engine Placelle Bulkhead

1. Electric Hydraulic Pump

1. Section of Cargo Floor

1. Propeller Blade

1. Reclass Utility-Bels

1. Section of Peroller Node

1. No. 4 Engineering

1. Boken Utility Pole.

1. No. 4 Engine Propelle

1. 2 Inboard Wing Plank Sections

1. Emergency, Escape Hotch

1. Braken Utility Pole

1. Remaining section of Right Wing

1. Section of Carg > Floor

1. New Seat

1. No. 3 Engine and Proçeller

1. Main Fusees

1. Fuselage Nose Section (Cockpit)

1. Right Stabilizer with Center a.d. Right Vertical Fins and Rudder attached

1. No. 2 Engine

1. Section of Engine Court

APPE AD 1X 0

NATIONA' TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C.

• 25 -

AYPENDIX E

ISSUED: September 11, 1974

Forwarded to:

Honerable Alexander P. Butterfield Administrator Federal Aviation Administration

Federal Aviation Administration

Washington, D. C. 20591

SAFETY RECOMMENDATION(S)

A-74-62 thru 64

On December 15, 1973, an Aircraft Pool Leasing Corporation Super Constellation L-1049H, operating as a cargo carrier, crashed into a residential area shortly after taking off from Miami International Airport, Miami, Florida. It was a nonscheduled cargo flight to Caracas, Venezuela, which was originally planned to operate under the provisions of 14 CFR 91D.

The National Transportation Safety Board's review of the flight engineer's medical records showed that from 1970 through 1973, three medical certificates were issued to him by an Aviation Medical Examiner (AME) in Miami, Florida. Although the certificate issued on November 16, 1973, was a First Class certificate, the application form indicates that the airman applied for a Second Class certificate. In addition, an applicant is required to take an electrocardiogram before he can be issued a First Class certificate. In this case, however, there is no record that an electrocardiogram was given.

The flight engineer's medical records also contain correspondence which indicates that he had tried to obtain a Second Class medical certificate in the Netherlands on December 3, 1971. In a letter to the FAA Aeromedical Certification Branch, dated December 16, 1971, the A&E in the Netherlands stated that the applicant's hearing and vision were inadequate. Additionally, the AME indicated that, in his judgment, the applicant was not mentally fit and might have been under the influence of alcohol or drugs during his examination. Because of these findings, the AME had given the applicant a letter of denial.

APPENDIX E

• 26 -

Hon. Alexander P. Butterfield

In the same letter, the examining AME also stated that he suspected the man had illegally obtained a presigned certificate from his office. A completed Second Class certificate dated December 3, 1971, which bore the AME's signature, was found among the personal belongings of the flight engineer following the above accident.

After receiving the letter, a representative of the Aeromedical Certification Branch advised the AME in the Netherlands that the computer had been "flagged" for subsequent applications by this man and that they would do everything possible to attempt to locate him. According to Acromedical Certification Branch personnel, there was no further correspondence relative to this matter in the man's medical file. Subsequent to the denial, however, the flight engineer was issued two medical certificates.

Our investigation also revealed that the flight engineer was an alcoholic. He had been enrolled in various rehabilitation programs, including one in which his condition was diagnosed by a physician as "severe chronic alcoholic," with "alcohol epilepsy." According to the medical records at the rchabilitation center, the flight engineer's convulsions began in 1966.

The toxicological analyses of the flight engineer's blood did not reveal basic drugs or alcohol. However, his blood did contain .58 mg. percent of meprobamate, a tranquilizer. FAA publication AC 91.11-1, "Guide to Drug Hazards in Aviation Medicine," states the following regarding the use of meprobamate: "Airman duties contraindicated for 24 hours after use; however, patients requiring tranquilizers are ordinarily excluded from duty."

In applications for medical certificates by the flight engineer, he denied having or having had, the following: Unconsciousness for any reason, epilepsy or fits, nervous trouble of any sort, any drug or narcotic habit, or an excessive drinking habit. There presently are no effective means to confirm the existence of such ailments which are disqualifying by 14 CFR 67A.

Although none of these findings have been directly related to the cause of the accident on December 15, 1973, deficiencies in the medical certification and surveillance process allowed a medically disqualified crewmember to participate in the conduct of the flight.

To prevent recurrence of the irregularities and deficiencies identified herein, the National Transportation Safety Board recommends that the Federal Aviation Administration:

• 27 -

APPENDIX E

Hon, Alexander P. Butterfield

1. Establish a system for the processing of airmen's medical records which will more effectively identify persons who have previously been denied a medical certificate.

1. Provide in your current program more effective guidelines to AME's by which to identify subtle, disqualifying ailments, such as alcoholism and nervous conditions and conduct periodic seminars to emphasize the importance of such factors.

1. Issue a Medical Alert Bulletin(similar to your Flight Standards Maintenance/Operations Bulletins) to AME's and other FAA medical personnel, incorpo-rating the essential elements of this case, to emphasize the need for thorough processing of medi-cal certification records, safeguarding of medical forms, and cautioning of presigning medical certifi-cates.

REED, Chairman, McADAMS, BURGESS, HALEY, Members, concurred in the above recommendations. THAYER, Member, was absent, not voting.

John W. Reed Chairman

NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C.

• 28 -

APPENDIX E

ISSUED: October 2, 1974

Forwarded to:

Honorable Alexander P. Butterfield

Administrator

Federal Aviation Administration

Washington, D. C. 20591

SAFETY RECOMMENDATION(S)

A - 74 - 82

On December 15, 1973, an Aircraft Pool Leasing Corporation Super Constellation L-1049H, N6917C, crashed into a residential area shortly after taking off from Miami International Airport, Miami, Florida. It was a cargo flight which was originally planned to operate under the provisions of 14 CFR 91 Subpart D.

The National Transportation Safety Board's investigation of the accident revealed deficiencies similar to those which, in October 1970, prompted the Secretary of Transportation to direct the Assistant Secretary for Safety and Consumer Affairs to conduct an indepth investigation of charter operations which use large aircraft. The assigned task force published its findings and recommendations on February 5, 1971, in "A Report to the Secretary on Investigation of Charter Aircraft Services" (The Smith Report).

As a result of one of the task force's recommendations, a truth-in-leasing clause was required in leases and conditional sales contracts (14 CFR 91.54). The intent of the provision was to assure that a potential lessee is aware of the responsibilities of being the operator of an aircraft.

The truth-in-leasing: clause requires that a copy of the charter or lease contract be mailed to the FAA Flight Standards Technical Division at Oklahoma City, Oklahoma, within 24 hours of its execution. Since the copy of the agreement arrives in Oklahoma City after the flight is completed, preflight surveillance is impossible. Therefore, safety is not served by compliance with this regulation.

APPENDIX E

• 29 -

Honorable Alexander P. Butterfield

After the Aircraft Pool Leasing accident on December 15, 1973, the Miami GADO initiated an intensive 24-hour surveillance program of all. 14 CFR 91 large aircraft operating from Miami International Airport. Although some operators have evaded surveillance by relocating their operations, the program has provided more effective surveillance and deterred illegal operations. The Safety Board realizes that an expansion of this program to other major airports would impose an excessive demand on FAA manpower and create an unreasonable imbalance in its safety program.

Consequently, the Safety Board believes that the FAA inspection office in the locale where the operator proposes to originate a flight subject to 14 CFR 91 Subpart D, could more effectively exercise surveillance if those offices were alerted by timely notification of the planned operation. If this were done, it would obviate the need for a continuous surveillance program and permit FAA to conduct this program on a planned basis.

The following discrepancies found in the investigation of the Miami accident might have been detected and the flight forestalled by FAA surveillance following an advanced notice of the operation:

(1) The first officer did not meet the second-in-command provisions of 14 CFR 91.213.

(2) The flight engineer did not meet the minimum flight time requirements of 14 CFR 91.211.

(3) The cargo was not secured as required by 14 CFR 91.203.

Accordingly, the National Transportation Safety Board recommends that the Federal Aviation Administration:

Amend 14 CFR 91.54 to require that the lessee or the conditional buyer give notice of the proposed departure time, date, and place, no later than 24 hours before the proposed departure time, to the Flight Standard District Office, Generati Aviation District Office, or Air Carrier District Office nearest to the airport where the flight will originate.

Members of cur Bureau of Aviation Safety will be available for consultation in the above matter if desired.

REED, Chairman, THAYER, BURGESS, and HALEY, Members, concurred in the above recommendation. McADAMS, Member, did not participate in the adoption of this recommendation.

By: John H. Reed Chairman