1975_美国_AAR7515.pdf

8 U.S. DEPARTMENT OF COSSERENCE Rational Technical information Service

NISUB/A/104-75/003

AIRCRAFT ACCIDENT REPORT -- WESTERN AIR LINES, INC., BOEING 737-200, N4527W, CASPER, WYOMING

March 1075

TECHINA REPORT ECHINA RE�AY� PAGIT

TABLE OF CONTENTS

PILLE 2001, II=1001

NATIONAL TRANSPUTATION SAFETY BORD WASHIBRIUM, D.C., 20594

Aircraft ACCIDENT REPORT

Adapted a October 30, 1975

WASTERN AIR LINBS. INC.

HORING 137-209. M527M

CASPER, WOMING

March 31, 1975

SYMPSTS

At 07th on March 31, 1975, Western Air Lines , Inc., Flight 470 , over- ran the departure of runway 25 at the Natron County International Airport , Casper , Wyoming . The looking was made following a nonprecision approach on a snow-covered runway, with a following wind , and during reduced viability. The aircraft was damaged substantially.

Of the 99 persons abosrd the aircraft , 4 were injured . Of these four injuries , three occurred during the evacuation.

The National Transportation Safety Board determined that the principle cause of the accident was the failure of the pilot in command to exercise good judgment when ne failed to execute a missed approach and continued a unpractilation approach to a landing without adequately assessing the area craft's position relative to the runway threshold . Contributing to the accident were the excessive height and spend at which he crossed the ap- proach end of the runway and the failure of other flight creasements to provide him with r ) : the callouts .

N. ARVIESKENAKI 2021

1. 1. History vE the Flight

On March 31, 1975, Western All Lines , Inc., Flight 470 , a Boating 737-700 , 195274 , operated as a scheduled passenger flight. Five Denver , Colorado , to Minneapolis/St. Paul , Minnesota . The first en route stop was Capper , Warmings .

Before Flight 470 departed Denver, the captain discussed the weather, viability, and rureasy conditions at Casper with the company dispatcher to los Angeles, California.

The Flight departed Denver at 0703 d/u. which 99 persons, including a creemembers, aboard. (2) was cleared to Caspor in accordance with a stored instrument flight units (1993) flight plan. The assigned on route

U. All classes herein are commerten daylight, based on the 24-hour clock.

· 2 ·

Flight level (FL) was 220. The flight was uneventful during takeoff, clain, and cruise.

Before the descent to Casper, the second officer prepared a landing data card which was based. In part on the 0700 Casper weather report, The card contained the following data:

Celling → under� at to, 800 feet, stay obtained; visibility in the light, a new temperature → 230; new point → 190; wind → 050 at 32 km; altiner → 29.68. The aircraft's gross weight → 93,300 lbs.; the go-around engine pressure ratio → 2.11; reference speed for approach → 126 km indicated airspeed (KIAS) at 40° flap setting, and 130 KIA5 with 30° of flaps.

A notation at the bottom of the card indicated "R/H 07 VR 7/H VI 2/12" use 30 flaps for an route being."

Flight 4/30 was about 40 nm from the Cooper VOR 3/ when Denver Center reekinated radar service. At 0736, following a descent to 12,000 fast, 4/ the flightsteres contacted Casper approach control and advised that the flight was about 12 nm south of the Evansville Intersection. 5/ At that time, the controller cleared the flight to use the localizer back course approach for runway 25, to circle to runway 3, or to land straight in. The Casper weather was given as an "indefinite calling, 800, sky obscured, visibility 1, variable with light snow, visibility 3/4 variable, 1 1/2. Visibility does appear lower than east; it appears right on one eant, and we have a strong own west." The when was given as "060" at 9." Use minute later, then approach controller� and was that "runway 7/25" has been plused. There's about a 1/4-15th of ponder arrow on k1. Braking section reported, Conmark '800 as poor. Turnway 3/21 in training pleased at this place."

Incorrelation Frontier Flight 80 was also on the approach control frequency. At 0740, the controller have Frontier 80 the local teacher conditions and indicated that other virtual was 100 as 10 km.

At 0751, flight $\frac{110}{}$ reported at the Handling Interaction of and was cleared to contact the Casper tocar. The manager controller cleared the flight to land on runsay 25 and gave the wind as 0360 at 8 km. "The

1. Runzay 07 wastabally Rigito = 7/8 ville wantabla en 1 1110.

M� Verty Hághá Fizypároscép Comtedelésítátorzál Nészlésé.

41 All dictatus hercin are seen one level的 rules of�ruals. And I

3/ The Interaction of the酸rowa County Interaction of the Aisport TS.B. back course localian and the 1510 radial of the Caoper HOK.

61 The Interaction of the back course local for to runway 25 and the 1840 radial of the Casper win.

• 3 “

flight was also adviked by the controller that a disabled arm blower was "just went of the interaction runway 21, left side runway 25, on the edge. . . ." The flightcrew acknowledged the transmission but asked which runway was cleared. Following the controller's statement on 0/12 that "Runway 25 is cleared for landing," the flight asked for the wind report and was told again that the wind was 0/10 at 8 km.

during posaccident interviews, the captain started that the aircraft and its systems operated normally and that he was flying the aircraft throughout the flight. No recalled that the aircraft crossed the ivance-ville Interconnection at 7,600 feet and the clearance to make a back course localizer approach was received about that time. He said that he accepted this approach because prevailing conditions not approach criteria; however, he stayed that he had mentioned to the other crewembers the possibility of executing a summary 25 released approach. If he did make a missed approach, he would proceed over the field and begin a front course 11.5 approach to run away 0.7. He said later that he had considered the walk and braking reports and the reports were acceptable. The first officer stated also that bug hunting a back course approach presented no problems to him and that it was routine for the cover to clear aircraft for straight-in approaches and landings when winds were less than 10 km.

both pilots related that the aircraft was in the approach configurations (tram, flaps 25°, imbling gear down, afreged 150 KAS, and altitude 6 , 100 feet , & At Hunting , both pilots began to tie the distance from the final "approach" fix to the closed approach point (H27). At 0741.102 , the captain started that the unspared them could be 1 minute 36 seconds; however, the first officer said Later that he had escarlated than a few to be 1 minute 20 seconds after the applied a wind factor. The Jeppeam approach place, which both pollute were using, it has a time interval of 1 minute 26 seconds and a decorum rate of 1, (40) feet per example in a ground speed of 140 KH. The distance however, the two points in 1.4th and the altitude difference is 1, 140 feet.

At 07/14/182, the first of the first called out, "thousand to go to the Ximal." 7/7 Tham, at the captains's direction, the first defense over the 2010 medical of the Champor VOR in the window of its course deviation in the -actor. At 07/14/182, the first officer called "approaching witnesses," and 12 associate later, the called "june about at maintenance." The cockpit, voice reminder (COR) recorded increasing engine wishes at this time,

Both plillors enacted that the aircraft flow level for a few consents at the well-known dement altitude (NDA) . Four seconds later, or at 0742125 , the first officer called the survey in right, unexpectedly below the aircraft . that plillors received that the all-speed was 150 km , within the trailing wign flamp near at 150 m . The first officer was adjusted the aircraft ' s dis- cavens to the runmeny threshold to be 1/6 call when the fire was righted the runmeny . When the first officer indicated that he had the runway in

1. Ehalid alvarat.Sama la 5,340 fear.

→ 64 →

right, the captain, who was flying by instrument reference, glanced out and activated the sasa distance to be 3/4 to 1 mile. The captain stated that from the point where he first signed the threshold and the high intensity runway lights, which he said were clearly distinguishable, he could see the sasa blower and about 1,000 foot of runway beyond the first runway interaction. The intersection is about 1,300 foot from the threshold. The captain requested a 40° flap setting; however, the second officer told the captain that 30° flaps were all that could be used. The captain then asked for a 30° flap setting, and the landing was made with a 30° flap setting. The captain stated later that descent was normal from IDA and that an "excessive" rate of descent did not develop. The first officer agreed. As the aircraft crossed the threshold, the second officer made a cabin announcement for the flight attandants to be stated.

According to the first officer, the airspand as the aircraft crossed the threshold was reference speed +15 km, and he began to look for runway distance markers but didn't see any. He recalled that after the aircraft was flared, it did not float. The touchdown was firm on the snow-covored runway, and the wing ground spoilers deployed normally. The first officer later said that ".,,shortly after the engines were placed in reverse, the red runway edge lights 8/ cano into vless." He believed that the aircraft touched down about 2,400 feet from the threshold. He was not apprahensive until he was the runway "s ciel.

According to the captain, the aircraft crossed the threshold at 200 to 250 foot above the ground and at an airspeed of "not over 20" km above reference speed. He thought that he had touched down about 1,000 foot past the first runway interaction. He stated that although it was farther than he wanted, he was not concerned about using excessive runway. He started an early filee which he attributed to the 756 foot lateral placement of the runway edge light. After the "realized the actual height above the runway, he executed a step-down flare that caused the aircraft to float. The filee began at a speed of about Vref + 15 km. Although he didn't like the stop-down filee as he performed it, the captain stated that it was acceptable to him. He then pushed the aircraft into the runway; the landing was fire, but not hard. The uniskild system released once and then operated normally. The capital tried to engage the thrust lower reversers several times before both reversers began to operate significantly. Directions control of the aircraft was not a problem throughout the landing. The filee indication that the landing was in jeupardy, according to the certain, was when he saw what he believed were the red runway edge light. The captain then realized that there was not sufficient runway length resulting to attempt to go around. He then attempted to avoid the aircraft away from the approach light structure.

Based on the length of the alerraft's tire track in the man, the touchdown point was near the controlline and about 2,375 feat from the

8/ Investigation and ready-kony at the public hearing disclosed that the runway edge lights on the last 1,700 foot of runway 25 are auber, not red. The only rail lights are chosen which marks the departure end of the runway.

→ 5 a

departure end of the runway, about 6, We't feet from the approach end of the runway.

The aircraft want off the departure end of the runway to the right of the center line. The pilot utated that the nose wheel steering was adequate to take the aircraft to the right of the approach light structures. After striking several metal stanchions in the first row of terminal bar lights, which were located 200 feet off the end of the runway, the aircraft struck a shallow irrigation ditch 280 feet off the runway end. The aircraft veared farther to the right and stopped about 800 feet beyond the departure end of the runway on a magnatic heading of about 900°.

At 0743:27, the first officer notified the tower to call the fire trucke.

1.2 Injuries to Persons

1.3 Damagno-10 Alkraft

The aircraft was damaged substarally.

1.6 Other Package

Three approach Rights on the first row of currual bar light, located 200 feet from the departure end of runway 25, were destroyed.

3.5 percebrant, KVÍŘÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍKÍ

The all circumstances were properly佟同 with for the flight. (See Appendix B.)

The flaglicker had received training in all nonpraction approaches; however, their training records allowed that such approaches had been made from VG, navigational facilities. Accordingly to the captain, he had made several back course in MS approaches recently on regular scheduled flights, having those approaches, the visibility had been such that he was able to see the ruesay environment early enough to perst him to descend over the threshold at an acceptable height and speed. The critical maneuver in the nonpraction approach is the decent from minimum decent altitude to that ruesay touchdown zone; however, the captain did not have training or too experience where he had floin to a point immediately before the pass without the ruesay environment in sight and where he was required to make a decision to land straight in or to begin a missed approach.

· 6 ·

1.6 Aircraft information

The aircraft was certified, equipped, and maintained in accordance with Federal Aviation Administration (FAA) requirements. (See Appendix C.) The gross weight and c.g. were within prescribed limits during cake-off and landing.

1.7 Mathematical Information

The terminal forecast for Casper, issued by the National Weather Service Forecast Office at Cheyenne, Wyoming, at 03/0 on March 31, 1975, valid for 24 hours beginning at 0400 was, in part:

0400 - 1400: Celling - 3,000 feet overcast, visibility - 5 miles, light snow, occasional calling - 1,000 feet, obacuration, visibility - 2 miles, light snow.

The offleal surface weather observations at Casper near the line of the accident were as follows:

0626 - Special, kdefinite ceiling $\cdots$ 00 pent obscuration, visibility $\cdots$ 1 mille variable, light snow, wind $\cdots$ 040° 14 km, altimeter setting $\cdots$ 29.68 inches, runway 07 -- runway visibility 1 1/4 milles, visibility $\cdots$ 3/4 mille variable to 1 1/2 milles.

0656 - indefinite ceiling - 800 feet obscuration, visibility - 11000, light snow, temperature - 230°F, dew point - 190°F, wind - 050° 12 km, altimeter setting - 29.68 inches, runsay 07 runsay visibility - 7/8 variable to 1 mile, visibility - 3/4 mile variable to 1 1/2 miles.

07/08 · Social, indefinite willing · · 500 feat obscuration, visibility · · 1 miles, variable. Light snow, temperature · · 23°F, deep point · · 19°F, wind · · 05°N km, all water setting · · 29.70 inches, runway 07 runway visibility · · 7/4 mile variable to 1 1/3 miles, visibility · · 3/4 mile variable to 1 1/2 miles, aircraft mishap.

The area forward which was issued by the National Weather Service Forecast Office at Kansas City at 0640, March 31, 1975, valid 0700 - 0100, was, in part, as follows:

Significant clowland weather. Wyoming, Mountains occasionally obscured above 6,000 - 11,000 feet in cloud and amr with viel-billion in valleyn and plainn occasionally below 3 miles, light muss. Tops above 20,000 feet.

Ling. Light, occasional moderate mixedicing in clouds and in price��ition behind cold front. Freezing level 8,000 feet southern Kansan slopling to surface northern Nebraska. Lowering to surface remainder area by 2200.

· 7 ·

1.6.10 No.6

The back course instrument approach to runway 25 at the Natrona County International Airport incorporates an 11.5 localizer signal which is transmitted on 116.3 Hz. The inbound course is 256°. The final approach fix is the intersection of the localizer course and the 184° radial of the Casper VOR, which is located 11.5 nm from the fix. This fix, designated "Henrung," is 3.8 nm from the approach end of runway 25. An inter-mediate fix is provided at the intersection of the localizer course and the 156° radial of the Camper VOR. This interaction is designated "Evausville" and is located 9.3 nm from the approach end of runway 25.

The Jeppesen approach chart, which depicts the Natrona County International Airport localizer back course for runway 25, datei February 22, 1974, was current at the time of the accident and was used by the flight-crew of Flight 470. The chart displayed the 201° radial of the Casper VOR pointing toward the approach end of runway 3. (See Appendix D.)

There were no known discrepancies to navigational alde reported at the time of the accident.

1.9 Communications

No communications difficulties were reported between the flight�ers and the air traffic controllers.

1.10 Averdruss and Ground Facilities

Runway 25 at the Narrona County International Airport is an asphalt surfaced runway, 0,661 feet long and 300 feet wide. A Jeppesen approach chart notation states that the counter 150-foot area of the runway is to be used. The elevation at the touchdown area is 5,130 feet. High intensically runway; lights are placed 10 feet from each side of the runway, or 120 feet apart, laterally, All elements were operating at the time of the accident, and the lights were being operated on the highest Intensity sitting (step 5). There are no approach lights or visual approach slope indicator (VASL) for runway 25.

Jun. 16 CR 139, Certification and Operations, Land Alports Serving CAB-Certified Air Carriers, Nationa County International Airport, was issued an Airport Operating, Certificate effective May 21, 1973. On February 13, 1975, a Grant of Exemption was issued to except the airport from safety equipment requirements. The requirements provided for the acquisition of airport firefighting and reserve vehicles which not the requirements of 14 CR 139.49(b)(2). The exemption terminated on May 15, 1975.

1.11 Flight Records

The aircraft was equipped with a Pairchild Hotel A-100 CVR, serial No. 2524. The CVR was not damaged and a normal readout of the tape was obtained.

• 意-

The aircraft was all equipped with a Faltarchild Model 5626 flight data recorder (Phi), markl to 5513. The fall medium was unamaged and all parameters had been recorded. There was no evidence of recorder malfunction or recording abnormalities. A normal roadout of the tape was obtained. (See Appendix F for approach profile and Appendix F for ground track.)

1.12 Workpackages

The aircraft run off the runway to the right of the cercling and destroyed three approach lights on stanchions 200 foot off the end of the rumway. The aircraft then collided with an irrigation ditch, and the right main landing gear assembly and the right powerplant separated from the aircraft. They were found 460 and 580 feet, respectively, off the end of the runway. The left main landing gear assembly separated par-cially and rotated ait. The left powerplant remained attached to the aircraft. The nose gear assembly collapsed rearward. The left and right wing trailing edge flaps were in the 30", extended position. The flap Indicator in the cockpit also indicated this position.

There was no evidence to indicate a failure of the aircraft's systems, structure, or powerplante before the aircraft left the runway surface.

Cockpit examination shussed differences between instrument settings on the captain's and the first officer's instruments. The captain's airshaped bug was set at 130 km, while the first officer's was set at 126 km. The captain's radio altimeter was not at 300 feet, the first officer's at 200 feet.

The altitude maximising selector was set at 21,000 fast.

in area of tire on the right main visual trucke exhibited punctu- break and scuile that resembled reversed rubber. The damgial tire area extended 3 to 4 times an time sideall and was used only on the right health wheel crunks. The trucke had regalsations from the aircraft when it impact the irrigational ditch. The discifting was ingled to the trad line,

1.13 Medical and Pathological Information

Medical examination of the commanders revealed no evidences of re-existing physical or physiological problems which could have affected childly judgments or performances.

During this function, a passenger broke his side while helping multister passenger.

5-24-5-26-5

Itare was no Fira.

· 9124 ·

Casper Ground Control's radioed the airport manager, who was in charge of the airport's emergency personnel, that Flight 470 had run off the runway. At the time, the airport manager and all emergency personal were involved in snow-removal operations. The airport manager, who was super-visiting snow-removal operations alongside runway 25 when Flight 470 landed, new the aircraft pass his location and disappear into a snow shower. En rouce to the accident scene, the airport manager requested that the tower controller give Western Air Lines station personnel clearance to proceed out to the aircraft and requested that Flight 470 be asked to change to the ground control frequency. The first person to arrive at the scene was the airport manager. When he arrived, the aircraft was being evacuated and there was no fixe. Approximately 7 minutes, or longer, after the first notification of the accident, the airport's quick-dash firetruck arrived on scene. The firetruck driver did not inspect the wreckage for fire or for fire hazards.

The airport manager later recalled that when he reached the aircraft, he heard the auxiliary power unit running. He also noticed that the flight creemembers were still award the aircraft. After assessing the situation and checking for injuries among the passed gors, the airport manager directed his efforts toward a living the passengers transported to an airport hanger. The firestruck was used to help other vehicles transport occupants of the aircraft to an manually point in the hangar.

1.15 Survival Aspects

This was a survivable account.

When the aircraft stopped, each pilot opened his side window to deter-tine if there was fire. Both stated that they saw none. The captain at" tempted to notify the cabin attendants to evacuate the passengers; how-ever, the cabin public announcement microphone had come loose from its holder and could not be dislodged from under the captain's seat. The first officer performed routine cockpit security duties and then performed the "emergency evacuation checklist to complete securing the cockpit. In his written statement, like first officer stated that, "Jack (the captain) then came up and turned the battery switch off." The fire ex-tigerisher handles had been pulled and rotated as required. However, the pilots did not know if the extinguishant had activated. When the pilots left the cockpit, the evacuation of the cabin was complete.

After the aircraft stopped, the second officer immediately went into the cabin and saw that the passengers were leaving. The flight attendants asked if they were to evaluate, and the second officer answered affirmantively. He then opened the right forward exit door and the slide inflated. According to a flight attendant, the left forward exit door was difficult to open, but with the assistance of the second officer, the door was opened and the slide inflated normally. The second officer vent out a forward door and around the left wing, where he helped three passengers

→ 203 →

who had left the cabin by the overwing exit. It stated that the aircraft was on its belly. The second officer indicator that the level position of the aircraft alded the evacuation considerably. A flight attomant at the left rear door called to the second officer to straighten the evacuation slide which had partially inflated after being released. After it was straightened, the slide fully inflated; however, it deflated slowly when it was extended fully. The slide was punctured by bazhed wire when it fell across a fence.

The flight attendant seated to the forward jumpseat said that after she had inflated the left entry door slide, passengers had opened the coat, closet on the left side behind the entry door to retrieve garment bag and were blocking the a vla. She shouted for them to continue the evacuation and pushed the passengers to keep them moving out the exit.

Both flight attendants stated on the aft jumpseat said that during the ground slide, deria was flying around in the cabin. They said that the waste container can out of the storage bin in the aft galley and spilled garbage on the floor. When the aircraft stopped, both flight attendants began "to open their respective doors. The flight attendant on the left side could not open the left aft door more than a crack. An off-duty flight attendant, who was sitting in seat 160, helped her open the left door. The flight attradent then pulled the inflation handle for the evacuation slide, but it only partially inflated until the second officer straightend it.

the flight attendant on the right side went to open the right aft service door and a passenger helped her solving it open. She deployed the slide and banger unsecualling passengers. With all flight attandants stated that when passengers are opened covering to their exits, they new severa's passengers in the center cabin area waiting to use the overusing exits. They showed to the passengers to come to the tour and exit. After all the passengers were out, the flight att�ants exited and attempted to assemble the passengers together.

Shortly the better, two flight attendants cooarded the aircraft to obtain personal belongings of the passengers and to obtain a first aid ric and oxygen bottles.

During the evacuation, one passenger broke his wrist while helping author, passenger.

Of the three minor injuries, two were incurred during evacuation. The third was received when a passenger was thrown about as the aircraft was sliding to a stop.

1.16 Tests and Research

House were conducted.

~ 200

1.17 G�ar Information

1.27.1 Uncontrolled Vehicular Traffic

Frontier Airlines Flight 603, a Convalis 580, had been waiting take-off clearance on runway 25 when Flight 470 made its approach. The flight-crew of Flight 603 saw the aircraft pass above them as they held clear of runway 25. After the landing, Flight 603 was cleared to taxi to the take-off end of runway 3. The Convalis was held in takeoff position for further clearance until the tower controller could verify that the runway was clear of snow-removal equipment. At that time, the controller could not see the entire length of runway 3 because the visibility was reduced in most directions by falling now. He was relying on information from a county vehicle to report when all vehicles were off the runway.

Inmediately after Flight 603 was cleared for takeoff and was on the takeoff roll, the tower controller sighted three vehicles on a middle-hold taxiway approaching runway 3. Falling snow had limited viability and the controller did not see the vehicles until they were almost entexing the runway. Re attempted to stop them by directing a hand-held real year control light at the vehicles. The other controller attempted two radios transmissions to the aircraft in an attempt to stop it. The transmissions were broken, and a complete, single transmission was not made. The controller believed that the aircraft's speed was too great to stop before reaching the path of the vehicles. The Convalr flex 60 to 80 feet above the cars. Those vehicles were transporting the passengers from the dial-abled aircraft to an assembly point in hanger No. 3.

In a statement to the Safety Board, the captain of Frontian Flight 603 said:

"The tower cleared Frontier 603 down runway 21 to hold in position on runway 3. Taxing down runway 21 the only ground vehicles I observed were the snow removal equipment at the east side of runway 21. After holding in position on runway 3 for some time, the tower cleared Frontier 603 for cake off. I asked the tower if the runway was clear of snow removal equipment; they answered that it was. At about 80 Kts the tower said, 'Fritter 60-† without Unishing the transmission. About two seconds later I made a normal rotation and noticed two vehicles approaching runway 3 from my left at a high-rate of speed. The vehicles contained across runway 3 and we want over the top of these at what I would estimate at between 60 and 80 feet.$^{1}$

1.17.2 Excerpts From Eastern Air Line Operations and Txingth, Manual

33

Operac koran 74mmuk

Section 3-12, page 1, dated August 1, 1974:

PLAT NOT FING STANDARD CALLIT FUCCURRES

"All IFR Approvalchaz

A., At final approach film or outow marker

1. Call ultimate roadings and compare with approach plate.

B. Call 1000 t above touchdown (above TDX for approach to straight in minimum or above airport elevation for approaches to circling infliz-zmu).

C. Call $50N/°$ waves; and above.

D. Call $100^3$ above sulumiums.

P. CaU 1 chế và 100000!

NOTE: (ON NOMPERCISION APPROACHES (100 CLID'SPEPE REFERENCE) AT $00^{9}$ AMOVE FIELD LEVEL, CALL RACH 100^{9}$ AMOVE FIELD LEVEL.

P., all declarations of common doc or more from locallier or glide slope.

"Um, All Agymoschines Irebuilding WITH When Meklow 1050" From Touchdown

A. Call of rate of 1060 fps or more.

R. Call our the airspared it. If it is with 10 minutes, or the uniform airspared for that interregulate flup putting (Flaps 1 throu flaps 30).

C. Call airspooned if in excess of $V_{REF}$ + 10 or if the airspooned is reduced to $V_{REF}$.

“判渾潤《政 奭氩湯 A.L.B.B.S.E.R

A. Set to 1500 on CLIPb Checklist (both PIlot).

B. During all approaches (V201-199), when 1,500' Light occurs on, call out 1994 Night on and set to 2000 feet. (This procedure applies to both high and low minimum Captains.)

spszagameh vacamation

AFTER AIRFANCE CONES TO A STOV STANDST POMXA SWITCH . . . . . BATTENY BRAKES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

· 13 ·

EMINGIRITY NEXT LICIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FLARS · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · $\cdot

SPILIMRAKES

START LEVERS V A O O O O O O O O CUTOPP

FINE SWITCH OVERNIDE BUNTONS (3). PUSH

FIRE SHITCHERS (ongines GAPU-if). PULI. & ROTATE

DNAC CP, เขาสร้างสรุปศิตินา

HATTERY S�ICH OFF

Training: Musica!

Se�on 2-6, pige 93, dated October 15, 1971.

"Use a& Radio Altimeter"

A. Set to 1500* on Club CheckList (both Pilors).

B. During Approach (when flying on instrument conditions) call our TAM Light ON and RESET.

NOTE: SET THE RADIO ALTINEER TO DH FOR THE U.S. APPROACH. SET IT AT 300° FOR ALL, NOR-PRICISION APPROACHES AND NOT AT FDA. THE 300° SETTING ON THR-PRICISION APPROACH CONSTITUTES A RADIO ALTINEER WARNIW GATE AND IS NEVER TO BE SET TO PUBLISHED HININHOS."

Session 2-8, page 62-63, dated October 15, 1971;

Non-Precision Approaches

Good judgment in flap usage and airspand selection in a prime condition on non-precision approach. Variable factors may affect the performance of the aircraft to such a degree that it is impossible to follow the approach profile on the letdown plate.

Examples of those variables area

A. Tallwind on approach

B. Necessity of maintaining 55% $N_1$ to provide sample heat for engine, anticiating.

C. A 10 mille procedure turn limitation.

$$ \rightarrow 160 $$

To accommodate these and other situations which may vary, it is often necessary to extend flaps earlier and to reduce speed sooner than recommended. Exercise caution in flap usage and never place the accept in a configuration which would make recovery difficult or impossible in the event of sudden engine failure.

NOTE: EXERCISE CAUTION TP. 000 ING FLAP DRA. TO EXPEDITE DERICHT, HIGH RATES OF DESCENT AND STEP DOWN ALTITUDES COMMON TO NON-PRECISION APPROACHES CAN BE A HAZARDOUS COMBINATION UNLESS THE PILOT IS CARRFUL. NOT TO OVERSHOOT DESIRED LEVEL, OFF ALTITUDES, HIGH SINK RATES ARE NEVER RECONDED, THE MACH MORE ACCEPTABLE TECHNIQUE OF REDUCING APPROACH SPEEDS ALON; WITH ASSOCATED REDUCED DESCENT RAYES SHOULD ACCOMEDIATE ALL, DESCENT PROPILES, "

Section 2-8, page 76, dated October 15, 1971:

"Factors Affecting Landing Distance"

" Floating just off the runway surface before touchdown must be avoided, as this procedure uses a large portion of the available runway. If the airplane should be over the recommended speed at the point of intended touchdown, deceleration on the runway is about three times greater than in the air. The airplane should be landed no near the 1000 point as possible rather than allowed to float in the air to bleed off speed.

"Consider an airplane that would never ly approach at 130 kPa, and require a moral landing distance of 4.00$^{1}$. With other conditions constant, flying over the threshold with 10 kts, excess speed at 140 and touching down 10 kts, over speed would increase total landing distance only 350$^{1}$. If this 10 kts, excess speed in bled off in the air before touchdown, landing distance will be increased by about 1200 to 1500.

"Height of the airplane over the end of the runway also has a very significant effect on total landing distance. For example, flying over the end of the runway at 100 a altitude rather than 50 could increase the total landing a distance results primarily because of the length of runway used up before the airplane actually touches down. Glide path angle also affects total landing distance. Even while maintaining the 50' height over the end of the runway, total landing is increased as the approach path becomes flatter. Glide path angle is a function of pilot technique and beat results will be obtained at a normal PS slide slope angle."

18 15

2. APILVSES AND CO��S100S

3.1 Analysis

The aircraft was certificated, equipped, and amultivated according to regulations. The gross weight and c.g. were within prescribed limits during takeoff at Denver and during the approach to Casper.

Boved on its investigation, the flightworkers's statements, and the performance analysis, the Safety Board concluded that the aircraft's power plates, airframe, electrical and pitotstatic instruments, flightwork control, and hydraulic and electric systems were not factors in this accident.

The flightcer was route- and airport-qualified into Natrono Count//International Airport. Further, Both pilots ind made frequent and reumst approaches into the airport, particularly the back course ILS approach to runway 25.

The 4th of The

Although visibility was reported to be variable from 3/6 to 1/2, and less, witnessing's at�ants and trustsory revawaled that very localized unemhowers had reduced the visibility in portions of the airport to be than than 3/4, and. The flight-sterms of Flight 670 reported that they had the runway in might 3/4, and the clienthold; however, they could not see more than 12 runway, lights ahead of them while on the runway. These runway lights end 200 feet apart; therefore, the surface� vislability available to the Flight-sterms probably was less than 1/2, and. The Flight-sterms wanted that forward vislability decreased was they programmed down the runway. This observation was verified when the flight-sterms stated that they were not able to see the end-of-russey, lights until shortly after consideration. The touchdown point was 2,3/5 feet from them runway; therefore, forward vislability at that point was probably less than 1/2, and.

After this runway had been played, 2 to 3 inches of light show had fallen before the approach of Flight 4/0, and the entire airport surface was covered. Because of this thin layer of sync, the runway edge was in discernible. The lack of contrast between the runway and surrounding terrain and the 320-foot lateral displacement of the runway edge lights may have given the captain the false interpretation of building lower than he actually was. This false impression may have caused the captain to flare the aftercraft higher above the surface of the runway than he should have desired; however the Safety Board bolleves that the captain should have been aware of this impression and should have taken action to compensate for it.

The Approach and Land车

During the descent from clustering, altitude, the several aftercer co- pleted the required landing data card for the pilot's reference during the

... しら ...

reproach to Campour. The information on the ward 1.4-2, and when we knew the an higher than the naverium all possible taxed in the company of 10 km for 10 km-ing on runway 23. 9/ The card also contained the constant result on $30^6$ E.l.ap. meeting would be required for landing because the Flight had encountered weather conditions an route conductance to a frerase, the hall; a 4000 E.l.ap. and ting could not be used. The alverace is a grove weight, reactivated this use of full flaps because of a climb grailment limitation then the name of a allowed approach.

when the second official computed the amount of the gross weight for landing , has subtracted the preplanned fuel hexone if 2000 years a week before ground waking . A more accurate landfall weight could have been obtained by instructing the actual fuel burroff from the actual tablebook of grown weight . The actual gross weight, when computed in this fashion, was a natural hundred pounds under the climb grandivene limitation for the use of 309° flaps on runway 25 . Since the captain had committed a innocent approach, this weight limitation should have been considered when he will be erected a runway for landing , particularly in whom of the prevailing stilled . According to the capital's testimony , he did not realise a part the wight of the attracting might be a 15dification during the approach.

This safety Board building that a decade to cover by unusually 23 or not to go back to Hall. I.S. upper-down 20 curary 07 would have been prevalent under the conlit-tion from which exact case. “This decadetion would have provided a favourable said and said, “ said, “ suppose I suppose I can’t, you like who’s an informal term would have provided all the guidance to the company criminal in the reduced variability.

The approach, an equivalent, was more at least 1 friend, given the thought the whole crafts were properly configured. Acorultarily, to the PIR groundout and circumstances of the capital and the first officer, the airapamient was from 15 in to 23 in above the reference spread (130 km) for the approach. No attempt was made to reduce the spread to the acceptable to ex-tation of reduction in impoi plus 10 km.

The PERR also always what five aircraft's a change-range rate to offer dangerous the final approach. First was about 750 ft./min. This x nten would have been acceptable had a headwerked existed; however, which a call behind the rate should have been increased to place the aircraft at the PDA at a sufficient distance from the runway through to continue the approach carefully and to cross the threshold at or near the recommended height of 50 ft. The captain stated that the aircraft was at 300 ft. at 3/A to 1 million from the runway, if the captain's measurement of his architecture was correct, only a small increase in the innocent rate would have been required to put the aircraft in the current position for landing.

The capital may have controlled take altitude more necessarily hard the First officer made decent callouts every 1000 feet from 2,000 feet above the touchdown zone elevation. These required roll to we're not made. This accident emphasizes the need for flight crewmubera to continue to make

9) Later in the approach, between Evanaville Intersection and the final approach fix, the Casper approach controller updated this weather report and the wind fell within allowable tolerance for loading.

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The captain did not determine, nor did he receive through required call- out of us assistance in determining , the effect of true air-spared on ground spared , which , in cure , who appeared by a following wind . This oversight placed the aircraft fictur-ther given the runway during the flaring manner was chain while temptation de-strad or realized . Although the captain's control of heighted name I limited by a little reduction restrictions untill him now the runway en- vimentment , like control of air-spared than more flexible , he did not plan , however , to re-value spread in an acceptable minimum . According to the op- ' cain ' s testimony , he realized that the aircraft was crossing the runway threshold at a high-phe of at least 200 feet and at a speed of at least 140 km. An active point the certain should have begun a million approach, The reduced vibibility which's prevented the fighter from making the departure of the railway and 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1.a 1.1

A private public for communication between the " whatever will after this increase to which de-ment on the ravenary and vengerers' health, who indicated, that, in the same possible on the reamining ramenam, The carginality becomes was to act to temper to a low temperature and the seerer to hear of the light, a tructures off the dependent caver ement of other ramenam.

The SMEKIMIMYY EVEUNKICH

Then shall be determined to be made of such measures and shall have been directed with love. However, however, I have been the first man in the office, and the first man in the office. The first man in the office was the first man in the office, and the first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the office. The first man in the office was the first man in the

One omalg. had been taken from their aircraft , the other was in position under the left walking . Humareons other ignition sources were present, such an "That" whether him taking and the mustillany power unit which was run- might . Had any of these ignitions were concerned " spilled Feel or hy- dreamed to fluid counter pressure, a disastrous fire could have resulted , "the captain and the firtr of it, however, I would have completed check emergency which down the door and their own named in the various attion of provemagements . An establishment of E-recon-mental could have been made after those occupation from would be completed , at which it has a more thorough transportation of other work-page could have been made taken .

Whence problems encountered during the evaluation could have been decriminal to the utility of the passengers and an anishment of fire had wrapped.

• $100$

Trevak, at least two of these main cabin exits were difficult to upon, The forward flight management " as difficulty with the left Korean's entry door and an act of light avendant " as difficulty with the left rear entry door apparently were quite similar. That is , they both were able to rotate the handle partially and the door opened partially ; however , the doors then appeared to jam in that position. There are two possibilities which could complain the difficulties with the door : ( 1 ) The latching mechanisms may have been affected by the crash forces and fusage deformation ; ( 2 ) the emergency evacuation girl-bare ware hooked up and the added force re- quired to pull the slide pack out of its container may have been greater than the flight attendants participated .

Second , obstructions blocked passengers attempting to exit the air- craft . These obstructions consisted of items ; such as cow-light covers , which broke loose inside the cabin and pieces of carryon baggage which were dislodged during the accident. Several passengers stated them they had difficulty getting from their seats to the exits because of those varlium items . The forward flight attendant said that a briefcase from beneath a passenger seat blocked the cockpit doorway until she was able to kick it out of the way . Finally, the contents of a trash container were dumped on the floor in the aft gailley areas; however, the trash did not adversely affect the evacuation .

Third , a coat closed door on the left front side of the cabin just after of the forward entry coor created an obstruction. The closet has a door which lateres toward the back of the aircraft and the hinges are forward . When open, the door comes within about 2 inches of a cabment on the right side of the air always . If the door is opened further, it willings en- ticularly arcared and eventually reach the bulkhead aft of the entry door . There , the door crewell in £2010 from the closed position until it launched against the forward wall According to the flight attendance's attainment and reamilitary , currying the evacuation several passengers stopped to open the coat closet door and retrieves their belongings , while they were doing the hairs the entire akale was blocked to the forward exits . Similarly, the flight attendant was blocked from directing the passengers to the forward erits . Evissumly , she was able to latch the door in its fully opened position, but not befor the evacuation had been delayed considerably.

7 The length of time to evacuate the aircraft was not determined . There was a contact from crumembers and passengers that it was accom- punished in an little at 60 seconds. However, in view of the numerous minor delays that occurred, and the fact that there were 92 adult pass- stranger aboard , 1/4 la more likely that the evacuation lasted over 1 minute and possibly as long as 2 to 3 minutes.

19, 은 왕으로 찾

Although resecure activities did $\omega$ affect the outcome of the acel-dent, the potential for injury, death, and property loss was extremely

19

high. The conformance of Flight 470 were responsible for the control of the passemegere and for think welfar a when the evacuation was complete. This control was maintained to a point by the flight secondance, who, at the direction of the captain, gathered the passemegere and accompanied them to a control point in a ingargar. The flight attendants assumed control and checked for infuries while waiting ambulances for the injured and instructions for disposition of the other passongers. The response, billites which the flight attendants assumed within the scope of their emergency duties and were carried out well.

However, one action by the flight attendants is considered questionable. After the evacuation, two flight attendants reboazded the aircraft to obtain personal belongings of the passengers and to obtain a first aid kit and the oxygen bottles. According to the attendants' statements, they did not see the first truck as the scene, yet they reenzered the damaged aircraft. The potential for fire or explosion was very real since fuel had been apilled and one of the aircraft's damaged engines was under the wing. Aircraft jet engine components contain enough hot mail to ignite fuel -- up to 20 minutes after engine shutdown. Purchase, the control valve on one of the walk-around coygas bottles in the overhead rack had been opened in the accident and oxygen was being discharged. The need to obtain a first aid kit and an oxygen bottle may have appeared valid at the time; however, when the risks are considered, the potential danger outwighed any benefit.

For several reasons, firefighting vehicles and personal did not arrive in a classify Fashion. The driver, who was designated to operate the firetruck, was operating a snowflow on railway 3/21 at the time of the accident. He was first alerted of the crash by ratio transmission which said that Flight 4/70 had overrun the runway. The airport manager called him and ordered film and one other man to get the firetruck and to tell the other personal to continue plossing.

Since the airport manager did not call for a general emergency response by his rescue personnel, he probably had downgrated the capital for such response, similarly, the emergency response personnel were given the impression first the emergency was less than major. The air-port manager had apparently based his actione on his analysis at the accident scene and the flight�crew's radio call that there was no fire.

Uncontrolled Vehicular Traffic

The Safe Board in greatly concerned about the near-accident about 10 minutes after Flight 470 had overrun runsay 25. If Frontler Ahrlines Flight 403 had collided which the uncontrolled vehicles which were crossing the active runway, the result could have been disastrous.

The Safety Board believes that positive motion should have been taken by the airport manager, in concert with the control tower, to insure that

“ 20 22

the critical areas of the airport remained closed until a thorough A.M.assum- of the emergency situation had been made . The Safety Board believes that all vihicular traffic on an airport should either be radio-equipped or under the direct control of a vehicle which in radio-equipped, par= ticularly in minimum visibility conditions.

2.2 Co.celumons

(a) PArvUdUe

1. There is no evidence of aircraft structure or component fall-ure or malfunction before the aircraft overran the departure of rudmary 25.

1. The flightcrew was aware of the airport and weather conditions at Casper.

1. The visibility conditions for runay 25 were slightly worse than forecast or reprinted.

1. The flightcrow was aware that the approach to runway 25 would be made with a following wind.

1. The flightinterrow was aware of the 320-foot lateral separation of the runsary edge lights.

1. The Flight Cross was aware of the short distance between the final approach fix and the runway threshold.

1. The captain, did not consider all factors whom he planned his approach to runway 25.

1. The captain realized that the aircraft was higher and amateur chamanoral when it cromewl the railway threshold.

1. The first officer did not make all of the required air-spared and altitude oillous during the approach.

1. The next officer did not monitor the flight instruments as required and therefore did not assist the captain in his of such information making process.

1. The flightorner did not realize how such runway had been over- them when the captain made the final declution to land.

1. Low vertical and lateral viability mode A6 difficult to luggage spread, height, and distance.

1. After toowdown, little difficulty was encountered in break- lung or according the aircraft clear of ground objects.

· 21 ·

1. Aircraft evacuation was completed in a finally meanway by the seconder officer and the flight attendance.

1. The captain's and the airport manager's decision that no danger of fire or explosion was present were premature, because of these decisions, emergency equipment would not have been readily available if fire had erupted from any one of the many sources.

1. The airport manager did not take positive action to close the airport until the situation was assessed properly or to control the nonradio-equipped vehicular traffic on the airport operational areas.

(b) Probable Cause

The National Transportation Safety Board determines that the probable causa of this accident was the failure of the pilot-in-command to exercise good judgment when he failed to execute a missed approach and continued a nonprecision approach to a landing without adequately assessing the air-craft's position relativity to the runway threshold. Contributing to the accident were the excessive height and speed at which he crossed the approach end of the runway and the failure of other flight cramsembers to provide him with required callouts.

RIGOENIENATIONS

As a result of this accident, the National Transportation Safety Board has submitted a recommendation to the deral Avkation Administration. (See Appendix II.)

BY THIS RATIONAL TRANSPORTATION SAFETY BOAND

/el. JOMI II. REED Challk�am

/a/ FRANCIS II. MADAHS Member

/s/ LEABEL, A. BUNGESS Member

/e/ WILLIAM R. HALEY Number

LOUIS II. THAYER, Number, did not participate in the adoption of this report.

October 30, 1975

→ 1366 →

APPRINDIEX A

THESTRICTICATARIA AEDIN MZARILAR

2. Imvaligation

The Safety Board was notified of the accident about 0800 on March 31, 1975. An Investigator from the Safety Board's Denver Field Office, and two investigators from the Safety Board's headquarters in Washington, D.C., went immediately to the scene. Working groups were established for operations, systems/structures, flight data recorder, and cockpit voice recorder. The witness interrogation and the weather, human factors, maintenance records, and pvorplants aspects of the investigation were handled by the established groups.

Participants in the onscene investigation included representatives of the Federal Aviation Administration, Western Air Lines, Inc., Air Line Pilot's Association, and the Board of Trustees, Patrona County International Airport.

2. Public Hearing

A 3-day public hearing was held at the Canada Inn, Casper, Wyoming, beginning May 20, 1975. Parties represented at the hearing were: The Federal Aviation Administration, Western Air Lines, Inc., Air Line Pilot's Association, National Weather Service, Board of Trustees, Ratrona County International Airport, Transport Workers Union, and the Professional Air Traffic Controller Organization.

• 24 -

APPEKDIX B

CISW INFORMATION

Captain Jack A. Mylanek

Captain Jack A. Mylenek, 58, was employed by Western Air Lines, Inc., on January 17, 1966. He holds Airline Transport Pilot Certificate No. 1512825, with ratings in airplane multiengine land B-737 and airplane single-engine land. He was upgraded to pilot-in-command of Boeing 737 aircraft on July 5, 1972. His first-class medical certificate was updated on December 20, 1974, and was lesseed without limitations.

Captain Mylenek's last proficiency check was performed satisfactorily in compliance with 14 CFR 121,441. His last on route competency report was completed satisfactorily in compliance with 14 CPR 440 on August 23, 1974. He had accumulated about 6,699 total flight-hours, 2,000 hours of which were in B-737 aircraft. He had 854 flight-hours of instrument time.

First Officer Anthony J. Cavaller

First Officer Anthony J. Cavalier, 39, was employed by Western Air Lines, Inc., on July 15, 1968. He holds Commercial Pilot Certificate No. 1859308, with ratings in air!-no multiengine land, Douglas DC-3, and instruments. His first-class medical certificate, issued without limitations, was updated on July 8, 1974.

This last flight and Simulator Proficiency Report was compided on January 21, 1975. He had accumulated about 8,900 total flight-hours, of which about 2,900 hours were in Boeing 737 aircraft. He had about 2,500 flight hours of instrument time.

Second Officer Charles W. Glasscock

Second Officer Charles A. Classcock, 35, was employed by Western Air Lines, Inc., on June 13, 1969. He holds Commercial Pilot Certificate No. 1345624, with ratings of airplane single- and multiengineering lane, rotorcraft-helicopter, instruments. His first-class medical certificate, issued without limitations, was updated on July 12, 1974.

During the period of his employment, observations of his competency, when performing as a flight cremember while an route, were recorded three times by a designated check airman.

Flight Attendance

All three flight atts iants were qualified in accordance with applicable regulations for emergency training.

25

Last recurrent training:

Jeanne Traville - March 13, 1975

Jane K. Ruther - May 15, 1974

All three flight attendants were qualified in the B-707, B-720, B-727, and B-737 aircraft.

· 26 ·

APPDX C

ALICXAPT IMPORTION

Boeling 737-247, Serial No. 2011, 16527W, was registered to Western Air Lines, Inc. It was certified and maintained according to procedures approved by the FAA. At the time of the accident, the aircraft had accumulated 14,076.46 flight-hours.

Flight Hours Since Checks:

Bug does :

*247.18 a company designation of the 290 series a.c.r.a.l.

40 答案 45

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• 3를 빛

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C.

APPENDIS N

ISSUED: November 23, 1975

forwarded to:

Humorablo Jameso B. Dou

Aing Administration

Federal Aviation Administration

Washington, D. C., 2059k

SAFETY RECOWENDAT 10M (5)

A=75=04

On March 31, 1975, Western Air Lines , Thec., Flight 470 (a B-737) ran off the end of runway 25 after a back course IIS approach to Patrono County International Airport , Casper , Wyoming . The National Transportation Safety Board ' s investigation of this accident revealed in the implementation of the Federal Aviation Regulations which pertain to crew- member emergency training. Specifically, the Safety Board believes that the provisions of 16 CFR 121,417 (c), regarding croomember emergency drills in the operation and use of exits and evacuation slides, are not being accomplished adequately by room airlines.

Juxing the above accident, the aircraft left the runway surface, struck three approach light structures and an irrigation ditch and stopped 500 feet beyond the departure end of the runway. When the order was given to evacuate, occupants deplaned through four main exits and two overving exits. Two flight attendants reported difficulties in opening the left forward and left rear main cabin doors. The difficulties with the door apparently were similar -- both flight attendants were able to rotate the door handles and partially open the doors, but they were unable to open the doors farther. Eventually, the flight engineer fully opened the forward door and an off-duty flight attendant helped to open the rear door.

Two possible reasons for these difficulties are: (1) The door structures or mechanical may have been deformed by crash forces or fuselage deformation, or (2) the force necessary to pull the evacuation slide out of the door mounted slide pack may have been greater than the flight attendants anticipated.

The Safety Board does not believe that the first possibility has any basis. Examination of the wreckage revealed that all four cabin doors operated normally following the accident and no evidence of damage to their recヘlanies was noted . Additionally, our evaluation of the accident diminution revealed that the crash force on this accident were within those out forth in 14 (FR 25,564 (b) as constituting a "minor crash landing."

• + 36 -

APPENDIX H

Honorable James R. Dow

The second possibility is a more plausible explanation of the flight attendants' difficulties with the doors. Western Air Lines fulfills the provisions of 14 CFR 121,417, Crownmember Emergency Training, by the use of films, aircraft familiarization, and on evacuation training mockup. Both flight attendants had received initial and recurrent emergency train-ing using an actual aircraft door and using the mockup containing a B=737 door; however, neither flight attendant had ever opened an aircraft exit door with an evacuation slide attached; nor is Western's mockup door equipped with . ide. Our investigators noted that the forces required to operate the mockup door are noticeably less than those required to open on actual aircraft door with the sidepack attached. Thus, we believe that neither flight attendant was adequately prepared to anticipate the forces necessary to open a cabin door in the emergency movie.

Recently , the Safety Board ' s investigation of a United Air Lines 10-10 emergency evcaution at Seattle International Airport on October 16, 1975 , disclosed that two operable exits were not used. Preliminary information indicates that the flight attendant who attempted to open them concluded that they were imperative because the actions involved in the movement of the handler to activate the door opening cycle were different than those which she had encountered in recurrent emergency training. Specifically , the required humble motion in the aircraft was more than twice that in the training mockup . This case further illustrates the need for representative proceedings and equipment during training to facilitate transfer of learning experiences.

The Safety Board has previously identified similar situations which indicated shortcomings in [11,..,2] attendant training: For instance, several cases were cited in the Board's special study, "Safety Aspects of Emergency Evacations from Air Carrier Aircraft." As a result of that study, the Safety Board recommended that 14 CFA [21,417] (c) be amended to eliminate the provision which permits demonstration rather than performance of drills in operation and use of emergency exits [A74-A11h]), We expressed the same concern in proposals submitted for the FAA's First Monthial Operations Review. The Safety Board is aware of the FAA*** efforts, such as Air Carrier Operations Bulletin No. 73-1, issued May 7, 1973, to emphasize "hands-cn" training, and we support these efforts; however, we are concerned that the "hands-on" training may not always be realistic.

The Board realized that the are of actual aircraft doors with every action alides attached may be impretical, however, we do believe it in reasonable to require training in a mockup that is realistic.

In view of the above, the National Transportation Safety Board recommends that the Federal Aviation Administration:

• 32 -

APPENDIX H

Honorable Junase K. Don

Require air carriers to comply with the provisions of the CFR 121.417 (c) (4) by the use of accurate and realistic equipment and procedures which accurately simulate emergency conditions, including the forces involved in opening exits in the emergency mode; and require that during each flight attendant's initial and recurrent training he operate emergency exit. which duplicate the Forcees encountered and actions necessary when such exits are opened in the emergency mode. (Chapter II)

REED, Chal reans, McADHS, PLAYER, BUSINESS, and HALLY, Members, concurred in the above recornerulation.

By the Code